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Perceived Effectiveness of Elder Abuse Interventions in Psychological Distress and the Design of Culturally Adapted Interventions: A Qualitative Study in the Chinese Community in Chicago

Perceived Effectiveness of Elder Abuse Interventions in Psychological Distress and the Design of... Hindawi Publishing Corporation Journal of Aging Research Volume 2013, Article ID 845425, 9 pages http://dx.doi.org/10.1155/2013/845425 Research Article Perceived Effectiveness of Elder Abuse Interventions in Psychological Distress and the Design of Culturally Adapted Interventions: A Qualitative Study in the Chinese Community in Chicago 1 1 2 3 XinQi Dong, E-Shien Chang, Esther Wong, and Melissa Simon Chinese Health, Aging, and Policy Program, Rush Institute for Healthy Aging, Rush University Medical Center, 1645 West JacksonBlvd, Suite675,Chicago,IL60612,USA Chinese American Service League, Chicago, IL, USA Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Correspondence should be addressed to XinQi Dong; xinqi dong@rush.edu Received 16 May 2013; Accepted 9 October 2013 Academic Editor: F. Richard Ferraro Copyright © 2013 XinQi Dong et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This qualitative study examines US Chinese older adults’ views on the perceived eeff ctiveness, challenges, and cultural adaptations of elder abuse interventions to psychological distress in the Chinese community in Chicago. A community-based participatory research approach was implemented to partner with the Chinese community. A total of 37 community-dwelling Chinese older adults (age 60+) participated in focus group discussions. Data analysis was based on grounded theory framework. Our findings suggest that older adults perceived social support, empowerment, and community-based interventions design as most eeff ctive to promote psychological well-being of victims. The perceived preferences were similar between elder abuse victims and non-victims. Strategies to culturally adapt evidence-based interventions were proposed with respect to nurturing filial piety values, familial integrations, and increased independence. Research and educational outreach initiatives were also discussed. This study has wide policy and practice implications for designing and deploying interventions to reduce psychological distress with respect to elder abuse outcome. Cultural relevancy of health interventions is important in the context of the Chinese communities. Collective federal, state, and community eor ff ts are needed to support the culturally appropriate design and implementation of interventions suitable for the needs of the Chinese older adults. 1. Introduction of morbidity and mortality, elder abuse continues to aeff ct the quality of lives among vulnerable older adults [4–7]. Of Elder abuse, sometimes referred to as elder mistreatment particular importance is the adverse health outcome of elder or elder maltreatment, is an important global health issue. abuse on victims’ psychological well-being. Abused older Elder abuse manifests in various forms including physical adults exhibit symptoms of depression, anxiety, fear, and abuse, sexual abuse, psychological abuse, caregiver neglect, unworthiness, amongst other forms of psychological distress and na fi ncial exploitation [ 1]. Available data suggest that 10% [8]. of US older adults aged 60 or older experience one or multiple The associations between elder abuse and psychological forms of abuse [2, 3]. Despite the accessibility of Adult Pro- distress highlight the urgent need for developing intervention tective Services in all fifty states, an overwhelming number programs addressing both elder abuse and psychopathology. Even though elder abuse has great public health relevance of abused older adults may pass through healthcare system undiagnosed and overlooked. Associated with increased risk to health care professionals, social services providers, and 2 Journal of Aging Research the community gatekeepers and leaders, we have incomplete 2. Methods understanding of evidence-based prevention and interven- 2.1. Conceptual Framework and Den fi ition. This study fol- tion strategies to assist victims of elder abuse [9, 10]. A lowed the conceptual framework of sociocultural context of number of studies have started to examine the eeff ctiveness elder abuse suggested by the National Research Council [1]. In of different intervention programs to reduce psychological this framework, elder abuse is defined as “intentional actions distress, including increased social support for both vic- that cause harm or create a serious risk of harm (whether or tims and perpetrators [11–13], victim empowerment [14], not harm is intended) to a vulnerable elder by a caregiver advocacy interventions [14–16], and cognitive behavior acti- or other person who stands in a trust relationship to the vation [17]. However, research on interventions to reduce elder; or failure by a caregiver to satisfy the elder’s basic psychological distress with respect to elder abuse outcome needs or to protect the elder from harm.” eTh Socio-Cultural remains scarce [18]. Arecentsystematicreviewfurther Context model focuses on the comprehensive assessment reported that existing interventions had limited effects on of vulnerability factors while considering the socio-cultural improving the social and psychological well-being of victims context and social embeddedness, which refers to the set of [10]. people in the social network between older adult and trusted In addition, there exist structural, cultural, and social others. It is the interactions among these components in barriers in help seeking among the victims. For elder abuse which elder abuse may take place, while at the same time victims, barriers to obtaining services may include physical guiding the proposed analysis in this report. frailty, cognitive impairment, and dependence on the abusers [19]. At the same time, victims may also serve in a caregiving or support capacity to their dependents or abusive family 2.2. Community-Based Participatory Research Approach. members, which in turn create different but equally chal- Community-based participatory research (CBPR) design has lenging barriers to the victims’ willingness and acceptance been reported as an important model for exploring the of needed services for themselves [20]. The issue of cultural issues of elder abuse in minority communities [25, 26]. diversity surrounding elder abuse further exemplifies a major Described as “a systematic inquiry with the participation of complexity in advancing the field of elder abuse intervention. those affected by the issue being studied, for the purpose of There exist knowledge gaps in understanding the cultural education and taking action or affecting social change” [ 27], complexities of effective psychological well-being care sup- CBPR allows researchers, community leaders, stakehold- porting victims of elder abuse, particularly for minority older ers, and members alike to form a synergistic collaboration adults including African, Hispanic, and Asian populations for community changes. In order to fully engage Chinese [21]. community through the preparation, conduct, and n fi dings Chinese population is one of the fastest growing minority dissemination of research processes, a community-academic groups in the U.S. Population estimates suggest that there are collaboration was formed between Rush University Medical 4.0million ChineseAmericans in theUnitedStates, compris- Center and Chinese American Service League (CASL), the ing 23% of the Asian American. Much of the health concern oldest and largest social service agency dedicated to serving of Chinese older adults is deeply related to family caregiving Chinese immigrants in the Midwest. In order to maximize guided by filial piety virtues. In Confucius teachings, filial cultural and linguistic sensitivity of our research eoff rts, piety dictates children’s obligatory roles and responsibilities we formed a community advisory board to provide over- of caregiving to aging parents [22, 23]. Whereas respect for all guidance ranging from research conceptualization and seniors is a deep-rooted cultural tradition, recent research preparation to the conduct and findings review [ 6]. Board suggests that elder abuse is an existing and pervasive health members were stakeholders and leaders enlisted through issue facing U.S. Chinese older adults [5, 24]. However, civic, health, social and advocacy groups, community centers, we are unaware of any studies that have examined the and clinics. Residents and opinion leaders were also invited to perceptions and preferred programs to reduce psycholog- join the bimonthly meetings. ical distress from the perspectives of community-dwelling Since the inception of this synergistic community- Chinese American older adults. Improved understanding academic collaboration, elder abuse has been identified as of important factors shaping effective care for older adults’ a pervasive health issue facing the Chinese community. psychological well-being brings significant implications for A number of initiatives were undertaken to improve our health care professionals, social services providers, and health understandings in this complex public health concern. We policy makers. investigated cultural perception of elder abuse in the Chinese In order to expand our knowledge base on elder abuse community through focus group discussions and in-depth interventions in a community-dwelling population of Chi- interviews [5–7]. A recent advocacy effort also included the nese older adults, the goals of this qualitative study were to (1) commemoration of the World Elder Abuse Awareness Day elicit the perceived effectiveness of elder abuse interventions (WEAAD). Proclaimed by President Obama, WEAAD is in reducing psychological distress, (2) explore similarities and now observed every year on June 15 in the U.S. as the oppor- differences in intervention preferences between the victim tunity to learn the signs of elder abuse and to empower older group and nonvictim group, and (3) identify strategies to adults with tools and information necessary to overcome abu- culturally adapt evidence-based intervention programs to sive situations [28]. eTh Chicago community commemorated reduce psychological distress in the Chinese aging popula- WEAAD for the first time in CASL. Residents were invited to tion. join focus group discussions regarding their views on elder Journal of Aging Research 3 abuse interventions. All study procedures were approved The length of discussions was determined by the levels by the Rush University Medical Center Institutional Review of interaction among participants. eTh facilitators proceeded Board. with topics when responses were exhausted. 2.3. Study Design and Procedure. This study utilizes both 2.4. Data Analysis. For analysis purpose, we performed survey questionnaires and semistructured focus group meth- descriptive statistical analysis based on survey results. In ods to investigate the experience of elder abuse among U.S. accord with the standard diagnosis of a positive screen, the Chinese older adults. We invited seniors who experienced screening was considered positive for elder abuse or neglect elder abuse as well as those who did not experience elder if a patient answered yes to any of the screening questions. abuse to participate. Our sample size was 37. In order to With respect to qualitative data, grounded theory pro- ensure diverse opinions, we planned to recruit one-third of vided a general framework to analyze and develop themes elder abusevictims andtwo-thirdsofnonvictimsinthe study and theories [31–33]. A bilingual research assistant rst fi tran- sample. scribed audio recordings into Chinese transcripts (different Elder abuse was measured using a self-reported instru- dialects used the same Chinese characters). The original ment derived from the Hwalek-Sengstok Elder Abuse Screen- Chinese transcripts were then imported into NVivo so-ft ing Test (H-S/EAST) and the Vulnerability to Abuse Screen- ware (NVivo, version 9) for analysis. Two bicultural and ing Scale (VASS) (Hwalek and Sengstock, 1986; Schoeld fi and bilingual researchers analyzed data in Chinese iteratively. Mishra, 2003). Sample questions included if participants felt Following grounded theory, they first labeled the texts with uncomfortable with someone in the family, have been called key words and phrases. eTh key words were coded and namesorput down,orbeenforcedbysomeone to do things analyzed for emerging categories. Two coders then compared their belongings without have been taken permission. In and discussed their sets of categories collectively to evolve addition, basic sociodemographic information was collected, dominant themes. eTh categorization of each response was including age, sex, education, marital status, household, not na fi lized until consensus was reached. Each category country of origin, years of residing in the U.S. and preferred was reviewed and a short summary was written for each language. category. Quotes from the Chinese transcripts that captured Participants were then invited to participate in semistruc- participants’ opinions and sentiments were then translated tured focus group discussions. Health behavior and inter- into English and incorporated to support each theme. eTh ventions are highly culturally mediated issues. Focus group essence of discussions could be truly captured by working technique is an important qualitative research technique. with the original language in which the focus groups took It is particularly well suited for an exploratory study for place. which previous health literature is limited and for generating hypotheses and models of human behavior [29]. Focus group 3. Results participants were recruited in accordance with the following eligibility criteria: (1) aged sixty years or older, (2) self- 3.1. Characteristics of the Study Population by the Presence identified as Chinese, and (3) reside in Chicago. Prior to sur- of Abuse. A total of 37 participants enrolled in the project vey questionnaires and focus group discussions, study par- (Table 1). Among these, 11 participants (29.7%) reported at ticipants gave written consents. All materials were prepared least one item in the abuse screening tool in the domain in simplified Chinese, traditional Chinese, and English. In of psychological, physical, na fi ncial abuse and exploitation. order to ensure cultural sensitivity of the study, participants There were more men than women who screened positive were then divided into four focus groups according to their for abuse. In the victim group, the majority (72.7%) were preferred dialect, including Cantonese or Mandarin [30]. married and received 0–8 years of education (36.4%) or 13 or Focus group interviews were guided by trained facilitators more years of education (36.4%). All of the participants who affiliated with CASL. Participants’ perception of elder abuse screened positive to abuse emigrated from Mainland China. interventions, perceived barriers, and facilitators of interven- tion programs were explored by the following questions. 3.2. Perceived Eeff ctiveness of Elder Abuse Interventions. We explored the perceived eeff ctiveness of elder abuse interven- (1) In general, what components in elder abuse interven- tions in reducing psychological distress using open-ended tionswillbemosteeff ctivetoreducepsychological questions. Intervention programs identified as most eeff ctive distress of abused seniors in our community? to leasteeff ctiveincludedsocialsupport,empowerment, (2) What components or approach in elder abuse inter- community-based interventions, advocacy, and psychologi- ventions will probably not work in reducing psycho- cal interventions (Table 2). logical distress of abused seniors in our community? Of all the dimensions identified, the majority of responses fell into the category of social support. Specicfi ally, increased (3) What are the creative ways or measures you can think peer group support, family support, and community support of to improve the interventions components? were viewed as beneficial elements to reduce distress of (4) How do we overcome these challenges to promote abused victims. Forinstance, supportgroup that reduces intervention programs in accordance with Chinese social isolation and further informs seniors of their rights cultural and linguistic contexts? may be helpful to victims. As one participant described, 4 Journal of Aging Research Table 1: Characteristics of the study population by the presence of step. Many participants held favorable views toward interven- elder abuse. tions delivered by community-based social services organi- zations. Community-based organizations that offer bilingual Yes No Any abuse and bicultural services have been viewed as a safe haven by (𝑁=11 ) (𝑁=26 ) immigrant older adults and perceived as the only available Age group, number (%) help resource for immigrants [5–7]. Participants perceived 60–69 5 (45.5) 8 (30.8) the easy access, prompt response, and flexibility to integrate 70–79 6 (54.5) 12 (46.2) interventions into existing programs as a plus to community- based intervention module. Advocacy and psychological 80+ 0 (0.0) 6 (23.1) intervention garnered least favorable views from our data Sex, number (%) analysis. Men 7 (63.6) 9(34.6 ) Women 4 (36.4) 17 ( 65.4) 3.3. Similarities and Dier ff ences on Perceptions of Interven- Education levels, years (%) tion Component between Victims and Nonvictims Groups. In 0–8 years 4 (36.4) 12 (46.2) addition, this study investigated the similarities and differ- 9–12 years 3 (27.3) 9 (34.6) ences regarding preferences on the intervention components 13 or more 4 (36.4) 5 (19.2) between the victims and nonvictims (Table 3). The majority of Marital status, number (%) responses on preferred intervention programs from victims fell into community-based interventions and empowerment, Married 8 (72.7) 19 (73.1) whereas for nonvictim respondents, empowerment, and Single 1 (9.1) 0 social support components received the most favorable views. Widowed 2 (18.2) 7 (26.9) Psychological interventions, including behavioral interven- Number of people in the household, tions and behavioral activations, remained least favorable by number (%) both groups. 13(27.3)6(23.1) 2-3 7 (63.6) 14 (53.8) 3.4. Perceived Challenges to Each Intervention Component. 4 or more 1 (9.1) 5 (19.2 ) This study also captured the potential challenges in the Origin, number (%) design of interventions from the perspectives of older adults Mainland 11 (100) 25 (96.2 ) (Table 4). A most commonly perceived challenge to advocacy pertains to the fear of limited actions. Participants expressed Hong Kong 0 0 that advocacy programs would not be effective if the design Taiwan 0 1 (3.8) and implementation only set out to enhance victim self- Others 0 0 care without actionable goals. Advocacy could easily be Number of years in the U.S., number interpreted as “knowledge” or “a type of explanation to (%) abusive situations” and thus may be rendered less effective. 1–10 3 (27.3) 6 (23.1) Furthermore, participants were aware of the potential imple- 11–20 2 (18.2) 7 (26.9) mentation barriers to other programs, such as empowerment 21–30 5 (45.5) 10 (38.5) and psychological interventions. Participants commented that empowerment programs would only be helpful if linking 31 or more 1 (9.1) 3 (11.5) with other elements, such as counseling or peer group Language ability, number (%) support element, that is, “empowerment does not work; if Cantonese 8 (72.2) 17 (65.4) victims are not provided with direct counseling help (and Mandarin 2 (18.2) 2 (7.7) support), then nothing can be resolved”. English 1 (9.1) 0 (0.0) The benefits of psychological interventions to reduce psy- Toishanese 0 (0.0) 7 (26.9) chological distress of victims remained least evident through- out the discussion. We suspect that the concept of behavioral activation or cognitive behavioral therapy may be foreign to community-dwelling older adults; hence there exists limited understanding on its benefits. Participants expressed the “If you have a speaker that experienced elder abuse to come major challenge pertaining to negative perceptions on psy- in and actually talk to the elders, then elders can connect with chological interventions and behavior interventions. There someone who understands what they are going through”. may be a high level of reluctance and shame in joining such Empowerment was identified as an eeff ctive process interventions. to help individuals maximize their confidence, skills, and Last, many seniors perceive intervention as a way abilities in order to regain control of their lives. Many to advocate for victims and their family members that participants perceived education as the rfi st step to inform “the community has to do something about it to pro- victims of their rights. In addition, participants also pointed vide them (victims) the protection and care that they to increased na fi ncial independence of victims as an initial deserve”. Journal of Aging Research 5 Table 2: Perceived eeff ctiveness of elder abuse intervention. Themes Subthemes Representative statements “I think you can have increased support from victims themselves, like support group type of things. If you have a speaker that experienced elder abuse to Peer group support come in and actually talk to the elders, then elders can connect with someone who understands what they are going through. eTh speaker can share his help-seeking experiences and provide guidance to other peers too.” “As family friends and relatives, we need to be patient and listen to their Family support problems.” Social support “eTh y need family and relatives to lend ears to hear their problems.” “(...) we need to get a support group together in the community centers. Before older adults realize any potential abusive situations, they can go to the support groups and let professionals intervene at the earliest possibility. Then Community support perhaps we can prevent abuse from happening.” “I was thinking that maybe there should be a place for those elders to enjoy the time or to talk about their problems with people there to help.” Phone calls and hotlines “I hope there is a bilingual hotline number to call, if anything comes up.” “Education is the first step. They (victims) need to have a clear understanding of what elder abuse is so that they know what is going on.” Education “If everyone conforms to Chinese traditional values to respect seniors, there would be no abuse at all. Therefore, education is important. If we educate everyone, then we can stop abuse.” “Counseling is important too, so that victims can talk freely about their Empowerment distress and frustrations.” Counseling “I think if a senior is abused, he/she will be very sad and painful. If we don’t provide counseling help,wewill notbeabletorelatetothattypeofturmoil and provide solutions. So I think counseling will be really critical.” “We need to improve the financial situations of abused seniors. If they can Enhance financial stand on their own feet financially, it may help them overcome abusive independence situations and decrease their risks to be victimized.” “I think the options we have may all be effective. But if I must pick one, I would Interventions delivered think community-based intervention would work best in our community, through community since seniors always turn to community social services agencies for help.” agencies “I think the community-based intervention model would work. If seniors Community- have problems, community organizations can always step in and help.” based “I think we should educate homemakers about elder abuse. On the one hand, intervention Integrate services to they can help us communicate and outreach to seniors. On the other hand, if existing social service they encounter any clients who may be victimized by abuse, they can help agencies report the cases. Homemakers should be more aware of these types of issues and advocate for seniors.” “We need to provide seniors with viable solutions. This could be one of the Understand current most important methods. Make sure the seniors are willing to listen. Advocacy situation and identify Newspapers and advertisement may be important as ways to advocate for potential solutions their rights. And provide them with potential solutions and ways out of the abusive relationships.” “It is important do something positive to alleviate their distress. For instance, I Psychological Behavior activation like painting. If I am distressed or frustrated, I would paint. It helps express intervention my feelings and frustrations. These types of changes may help victims as well.” 3.5. Strategies to Culturally Adapt Elder Abuse Interventions help seniors”. eTh importance of educating and nurturing in Chinese Communities. In light of the perceived challenges filial piety values was echoed throughout the discussions. in the design of interventions, we also solicited ways to In addition, our analysis showed that improved peer adapt existing elder abuse interventions for Chinese seniors support by organizing community social events and activities in accordance with Chinese cultural and linguistic charac- may be a viable option to increase cultural sensitivity of inter- teristics (Table 5). Most of the responses fell in the category vention programs. One participant proposed that support of improving filial piety practice as a way to improve social group discussions may be integrated with existing cultural support. As one participant claimed, “Parents will feel much programs oer ff ed by community centers. Participants also better if their children are filial. This is the best measure to called for more research and educational outreach eoff rts 6 Journal of Aging Research Table 3: Similarities and differences on perceived preferences of intervention components between victims and nonvictims groups. Proportion of Proportion of Among victims Among nonvictims responses responses Community-based 31.5% Empowerment 32.3% intervention Empowerment 31.5% Social support 27.9% Community based Social support 22.2% 22% intervention Advocacy 9.3% Advocacy 8.8% Psychological 5.5% Psychological 8.8% Table 4: Perceived challenges in the design of intervention. Themes Subthemes Representative statements “I think advocacy is not going to be useful unless you help seniors to take real actions. You need actual changes to stop abuse, not only advocating for the Advocacy will be helpful rights of seniors.” if linking to actual “Among all the components, I think advocacy is least actions to stop abuse useful. Advocacy is only knowledge, a type of Advocacy explanationtotellpeoplewhattodo. It is toofar reached and actual impact is unclear.” “We should think about the abuser. Why are they eTh root of theissueisto abusing the elderly? Maybe the abusers have some stop abusers problems or stress management issues; we should also talk to them and see how they feel.” “Empowering seniors is an added value to the intervention. It does not help solve the real problem.” Empowerment will be “Empowerment does not work. If victims were not Empowerment helpful if linked with provided with counseling...(and support), nothing counseling can be resolved. Victims will still feel lonely and frustrated.” “Some people don’t even want your help, they would be like,goaway, Idon’t need it,it’sgoing to make my The concept may be life worse for me...that’s what older people might foreign to community Psychological think...Are they going to accept that? If they go to seniors and hence intervention therapy, they may say that they don’t think they have decrease thechanceof any problems. Older people have that attitude. So using this intervention how are you going to persuade them to go to therapy and change any types of behaviors?” Health surveys were perceived as a helpful way to equip similar between victim and nonvictims. Strategies to tailor older adults with necessary health sciences knowledge. In interventions toward Chinese cultural beliefs were also pro- addition, rigorous research contributes to the identification posed with respect to nurturing filial piety values, familial of seniors at high risks of abuse as well as those “who need the integration, and improving independence of victims. most help from us”. Last, increasing religious involvement was This qualitative investigation provides new insights on recognized as a helpful strategy. Participants linked religious how minority older adults viewed different abuse interven- attendance with increased social support, and thus it may be tion components and strategies to overcome intervention an eecti ff ve intervention for victims. barriers. First, our ndin fi gs provide direction for violence- related intervention services. A multidisciplinary approach that includes strengthening the informal support system 4. Discussion including family members, friends, and community gate- keepers as well as facilitating access to formal services In this first exploratory study of perceived effectiveness, building on the health care system warrants exploration in challenges, and cultural adaptations of elder abuse inter- this context. ventions among community-dwelling Chinese older adults, It has been argued that older adults with fewer psychoso- our ndin fi gs suggest that older adults viewed social support, cial resources or more psychosocial deficits seem to be more empowerment, and community-based interventions design vulnerable to elder abuse, and elder abuse seems particularly as most effective to vulnerable victims. The preferences were Journal of Aging Research 7 Table 5: Strategies to culturally adapt elder abuse interventions in the chinese communities. Themes Subthemes Representative statements “Parents will feel much better if their children are filial. This is the best way to help seniors. Much better than improving other types of social support. So we need to educate our children and grandchildren and try to avoid family Improve and nurture conflicts.” filial piety “Abusive situations can be much improved upon if children are filial. If they respect seniors, they will feel much better. Wouldn’t you say that this is the best way to improve the mental health of victims?” Improve social support “We can organize more social events and activities for older adults. I think Chinese seniors are oeft n lonely. Especially those who may encounter problems and conflicts at home. If we can get them to go to those support groups, it will help ease their minds.” Improve peer support “Seniors need to make more friends, especially with those who are currently undergoing similar issues. We need to get Chinese victims all together, like having them go to the same group discussion in community centers aer ft some sort of painting classes or tai-chi classes.” “eTh U.S. government should be attentive of the social welfare needs of Provide financial Enhance victims’ immigrant older adults. I think if abused seniors have more financial means, independence financial independence or financially more stable, they may not need to depend on the abusers at all, which will help improve their independence.” “We need to organize more educational workshops and group activities. It will be helpful if seniors are educated and informed of the benefits to Provide education interventions.” Research through research and “We need more research and health surveys that gather comprehensive health workshops information of seniors. We will be able to document the health and well-being of seniors this way and reach out to those who need the most help from us.” “I believe we can try to help them by increasing their religion involvement. If Provide victims with Religion they have higher religious attendance, they may be able to get more social religious support support as well.” detrimental to psychological well-being for victims [34]. Our future research is needed to move forward to designing data suggest that the increased social support from family, multicomponent elements of interventions suitable for the friends, and supports is viewed as amongst the most eeff ctive needs of minority older adults. For instance, studies in tribal interventions in increasing psychosocial resources of victims. communities found that interventions that oeff r combina- This ndin fi g resonates with respect to important Chinese tionsofindividualorfamilycounseling, case management, traditional values of filial obligations of respect and care from skills training, and behavior management strategies may be older adults. Despite acculturation challenges brought about more effective than interventions that only provide a peer by immigration, many traditional values and practices are support group [37]. Measures that provide the opportunity still entrenched in this community. eTh utilization of family for older adults, caregivers, families, and health professionals power in intervention designs warrants further attention. to come together to prevent and mitigate elder abuse in a It is also worth noting that advocacy and psychological community setting may be a novel option for Chinese older interventions received limited appraisal among participants. adults. Advocacy programs aim to enhance abused victims’ self- Furthermore, the results highlight the need to alleviate care by helping them to make sense of the situation, identify older adults’ fears and shame in disclosing abuse. Our nd- fi potential solutions, and achieve the goals they have set ings reveal that there exist more similarities than differences [24]. From the limited empirical evidence, the effect of in the preferences of intervention programs between suscep- advocacy intervention designed to improve quality of life tiblevictims andnonvictims. Although thefindingmay be and mental health of Chinese abused women remained to duetoasmallsamplesizeeeff ct,the violence andmental be seen [14–16]. Similarly, whereas cognitive behavior model health stigma may indeed aeff ct older adults’ willingness to remained less favorable, some researches suggest that it can enroll in intervention programs. Health care providers should be a viable model in Chinese American population, with consider outreach programs particularly designed to reduce afew modicfi ations [ 35, 36]. Systematic research is needed the stigma of violence and caregiver stress among Chinese to explore the eeff ctiveness of the different components of immigrant families. the advocacy and psychological intervention for the various Last, conducting participatory research approach allows forms of elder abuse. us to prioritize sensitive cultural context and increase the In addition, given that community-based intervention relevance of our research n fi dings to actionable interven- module is appraised by Chinese older adults in this study, tion goals [38, 39]. When culture is continually evolving, 8 Journal of Aging Research the ability to identify factors that are amendable to adaptation [2] S. R. Beach, R. Schulz, N. G. Castle, and J. Rosen, “Finan- cial exploitation and psychological mistreatment among older to theChinese population wouldhelpensurethatthe health adults: differences between African Americans and non-African intervention is sensitive to the needs and concerns of victims. 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Perceived Effectiveness of Elder Abuse Interventions in Psychological Distress and the Design of Culturally Adapted Interventions: A Qualitative Study in the Chinese Community in Chicago

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Copyright © 2013 XinQi Dong et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2013/845425
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Hindawi Publishing Corporation Journal of Aging Research Volume 2013, Article ID 845425, 9 pages http://dx.doi.org/10.1155/2013/845425 Research Article Perceived Effectiveness of Elder Abuse Interventions in Psychological Distress and the Design of Culturally Adapted Interventions: A Qualitative Study in the Chinese Community in Chicago 1 1 2 3 XinQi Dong, E-Shien Chang, Esther Wong, and Melissa Simon Chinese Health, Aging, and Policy Program, Rush Institute for Healthy Aging, Rush University Medical Center, 1645 West JacksonBlvd, Suite675,Chicago,IL60612,USA Chinese American Service League, Chicago, IL, USA Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Correspondence should be addressed to XinQi Dong; xinqi dong@rush.edu Received 16 May 2013; Accepted 9 October 2013 Academic Editor: F. Richard Ferraro Copyright © 2013 XinQi Dong et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This qualitative study examines US Chinese older adults’ views on the perceived eeff ctiveness, challenges, and cultural adaptations of elder abuse interventions to psychological distress in the Chinese community in Chicago. A community-based participatory research approach was implemented to partner with the Chinese community. A total of 37 community-dwelling Chinese older adults (age 60+) participated in focus group discussions. Data analysis was based on grounded theory framework. Our findings suggest that older adults perceived social support, empowerment, and community-based interventions design as most eeff ctive to promote psychological well-being of victims. The perceived preferences were similar between elder abuse victims and non-victims. Strategies to culturally adapt evidence-based interventions were proposed with respect to nurturing filial piety values, familial integrations, and increased independence. Research and educational outreach initiatives were also discussed. This study has wide policy and practice implications for designing and deploying interventions to reduce psychological distress with respect to elder abuse outcome. Cultural relevancy of health interventions is important in the context of the Chinese communities. Collective federal, state, and community eor ff ts are needed to support the culturally appropriate design and implementation of interventions suitable for the needs of the Chinese older adults. 1. Introduction of morbidity and mortality, elder abuse continues to aeff ct the quality of lives among vulnerable older adults [4–7]. Of Elder abuse, sometimes referred to as elder mistreatment particular importance is the adverse health outcome of elder or elder maltreatment, is an important global health issue. abuse on victims’ psychological well-being. Abused older Elder abuse manifests in various forms including physical adults exhibit symptoms of depression, anxiety, fear, and abuse, sexual abuse, psychological abuse, caregiver neglect, unworthiness, amongst other forms of psychological distress and na fi ncial exploitation [ 1]. Available data suggest that 10% [8]. of US older adults aged 60 or older experience one or multiple The associations between elder abuse and psychological forms of abuse [2, 3]. Despite the accessibility of Adult Pro- distress highlight the urgent need for developing intervention tective Services in all fifty states, an overwhelming number programs addressing both elder abuse and psychopathology. Even though elder abuse has great public health relevance of abused older adults may pass through healthcare system undiagnosed and overlooked. Associated with increased risk to health care professionals, social services providers, and 2 Journal of Aging Research the community gatekeepers and leaders, we have incomplete 2. Methods understanding of evidence-based prevention and interven- 2.1. Conceptual Framework and Den fi ition. This study fol- tion strategies to assist victims of elder abuse [9, 10]. A lowed the conceptual framework of sociocultural context of number of studies have started to examine the eeff ctiveness elder abuse suggested by the National Research Council [1]. In of different intervention programs to reduce psychological this framework, elder abuse is defined as “intentional actions distress, including increased social support for both vic- that cause harm or create a serious risk of harm (whether or tims and perpetrators [11–13], victim empowerment [14], not harm is intended) to a vulnerable elder by a caregiver advocacy interventions [14–16], and cognitive behavior acti- or other person who stands in a trust relationship to the vation [17]. However, research on interventions to reduce elder; or failure by a caregiver to satisfy the elder’s basic psychological distress with respect to elder abuse outcome needs or to protect the elder from harm.” eTh Socio-Cultural remains scarce [18]. Arecentsystematicreviewfurther Context model focuses on the comprehensive assessment reported that existing interventions had limited effects on of vulnerability factors while considering the socio-cultural improving the social and psychological well-being of victims context and social embeddedness, which refers to the set of [10]. people in the social network between older adult and trusted In addition, there exist structural, cultural, and social others. It is the interactions among these components in barriers in help seeking among the victims. For elder abuse which elder abuse may take place, while at the same time victims, barriers to obtaining services may include physical guiding the proposed analysis in this report. frailty, cognitive impairment, and dependence on the abusers [19]. At the same time, victims may also serve in a caregiving or support capacity to their dependents or abusive family 2.2. Community-Based Participatory Research Approach. members, which in turn create different but equally chal- Community-based participatory research (CBPR) design has lenging barriers to the victims’ willingness and acceptance been reported as an important model for exploring the of needed services for themselves [20]. The issue of cultural issues of elder abuse in minority communities [25, 26]. diversity surrounding elder abuse further exemplifies a major Described as “a systematic inquiry with the participation of complexity in advancing the field of elder abuse intervention. those affected by the issue being studied, for the purpose of There exist knowledge gaps in understanding the cultural education and taking action or affecting social change” [ 27], complexities of effective psychological well-being care sup- CBPR allows researchers, community leaders, stakehold- porting victims of elder abuse, particularly for minority older ers, and members alike to form a synergistic collaboration adults including African, Hispanic, and Asian populations for community changes. In order to fully engage Chinese [21]. community through the preparation, conduct, and n fi dings Chinese population is one of the fastest growing minority dissemination of research processes, a community-academic groups in the U.S. Population estimates suggest that there are collaboration was formed between Rush University Medical 4.0million ChineseAmericans in theUnitedStates, compris- Center and Chinese American Service League (CASL), the ing 23% of the Asian American. Much of the health concern oldest and largest social service agency dedicated to serving of Chinese older adults is deeply related to family caregiving Chinese immigrants in the Midwest. In order to maximize guided by filial piety virtues. In Confucius teachings, filial cultural and linguistic sensitivity of our research eoff rts, piety dictates children’s obligatory roles and responsibilities we formed a community advisory board to provide over- of caregiving to aging parents [22, 23]. Whereas respect for all guidance ranging from research conceptualization and seniors is a deep-rooted cultural tradition, recent research preparation to the conduct and findings review [ 6]. Board suggests that elder abuse is an existing and pervasive health members were stakeholders and leaders enlisted through issue facing U.S. Chinese older adults [5, 24]. However, civic, health, social and advocacy groups, community centers, we are unaware of any studies that have examined the and clinics. Residents and opinion leaders were also invited to perceptions and preferred programs to reduce psycholog- join the bimonthly meetings. ical distress from the perspectives of community-dwelling Since the inception of this synergistic community- Chinese American older adults. Improved understanding academic collaboration, elder abuse has been identified as of important factors shaping effective care for older adults’ a pervasive health issue facing the Chinese community. psychological well-being brings significant implications for A number of initiatives were undertaken to improve our health care professionals, social services providers, and health understandings in this complex public health concern. We policy makers. investigated cultural perception of elder abuse in the Chinese In order to expand our knowledge base on elder abuse community through focus group discussions and in-depth interventions in a community-dwelling population of Chi- interviews [5–7]. A recent advocacy effort also included the nese older adults, the goals of this qualitative study were to (1) commemoration of the World Elder Abuse Awareness Day elicit the perceived effectiveness of elder abuse interventions (WEAAD). Proclaimed by President Obama, WEAAD is in reducing psychological distress, (2) explore similarities and now observed every year on June 15 in the U.S. as the oppor- differences in intervention preferences between the victim tunity to learn the signs of elder abuse and to empower older group and nonvictim group, and (3) identify strategies to adults with tools and information necessary to overcome abu- culturally adapt evidence-based intervention programs to sive situations [28]. eTh Chicago community commemorated reduce psychological distress in the Chinese aging popula- WEAAD for the first time in CASL. Residents were invited to tion. join focus group discussions regarding their views on elder Journal of Aging Research 3 abuse interventions. All study procedures were approved The length of discussions was determined by the levels by the Rush University Medical Center Institutional Review of interaction among participants. eTh facilitators proceeded Board. with topics when responses were exhausted. 2.3. Study Design and Procedure. This study utilizes both 2.4. Data Analysis. For analysis purpose, we performed survey questionnaires and semistructured focus group meth- descriptive statistical analysis based on survey results. In ods to investigate the experience of elder abuse among U.S. accord with the standard diagnosis of a positive screen, the Chinese older adults. We invited seniors who experienced screening was considered positive for elder abuse or neglect elder abuse as well as those who did not experience elder if a patient answered yes to any of the screening questions. abuse to participate. Our sample size was 37. In order to With respect to qualitative data, grounded theory pro- ensure diverse opinions, we planned to recruit one-third of vided a general framework to analyze and develop themes elder abusevictims andtwo-thirdsofnonvictimsinthe study and theories [31–33]. A bilingual research assistant rst fi tran- sample. scribed audio recordings into Chinese transcripts (different Elder abuse was measured using a self-reported instru- dialects used the same Chinese characters). The original ment derived from the Hwalek-Sengstok Elder Abuse Screen- Chinese transcripts were then imported into NVivo so-ft ing Test (H-S/EAST) and the Vulnerability to Abuse Screen- ware (NVivo, version 9) for analysis. Two bicultural and ing Scale (VASS) (Hwalek and Sengstock, 1986; Schoeld fi and bilingual researchers analyzed data in Chinese iteratively. Mishra, 2003). Sample questions included if participants felt Following grounded theory, they first labeled the texts with uncomfortable with someone in the family, have been called key words and phrases. eTh key words were coded and namesorput down,orbeenforcedbysomeone to do things analyzed for emerging categories. Two coders then compared their belongings without have been taken permission. In and discussed their sets of categories collectively to evolve addition, basic sociodemographic information was collected, dominant themes. eTh categorization of each response was including age, sex, education, marital status, household, not na fi lized until consensus was reached. Each category country of origin, years of residing in the U.S. and preferred was reviewed and a short summary was written for each language. category. Quotes from the Chinese transcripts that captured Participants were then invited to participate in semistruc- participants’ opinions and sentiments were then translated tured focus group discussions. Health behavior and inter- into English and incorporated to support each theme. eTh ventions are highly culturally mediated issues. Focus group essence of discussions could be truly captured by working technique is an important qualitative research technique. with the original language in which the focus groups took It is particularly well suited for an exploratory study for place. which previous health literature is limited and for generating hypotheses and models of human behavior [29]. Focus group 3. Results participants were recruited in accordance with the following eligibility criteria: (1) aged sixty years or older, (2) self- 3.1. Characteristics of the Study Population by the Presence identified as Chinese, and (3) reside in Chicago. Prior to sur- of Abuse. A total of 37 participants enrolled in the project vey questionnaires and focus group discussions, study par- (Table 1). Among these, 11 participants (29.7%) reported at ticipants gave written consents. All materials were prepared least one item in the abuse screening tool in the domain in simplified Chinese, traditional Chinese, and English. In of psychological, physical, na fi ncial abuse and exploitation. order to ensure cultural sensitivity of the study, participants There were more men than women who screened positive were then divided into four focus groups according to their for abuse. In the victim group, the majority (72.7%) were preferred dialect, including Cantonese or Mandarin [30]. married and received 0–8 years of education (36.4%) or 13 or Focus group interviews were guided by trained facilitators more years of education (36.4%). All of the participants who affiliated with CASL. Participants’ perception of elder abuse screened positive to abuse emigrated from Mainland China. interventions, perceived barriers, and facilitators of interven- tion programs were explored by the following questions. 3.2. Perceived Eeff ctiveness of Elder Abuse Interventions. We explored the perceived eeff ctiveness of elder abuse interven- (1) In general, what components in elder abuse interven- tions in reducing psychological distress using open-ended tionswillbemosteeff ctivetoreducepsychological questions. Intervention programs identified as most eeff ctive distress of abused seniors in our community? to leasteeff ctiveincludedsocialsupport,empowerment, (2) What components or approach in elder abuse inter- community-based interventions, advocacy, and psychologi- ventions will probably not work in reducing psycho- cal interventions (Table 2). logical distress of abused seniors in our community? Of all the dimensions identified, the majority of responses fell into the category of social support. Specicfi ally, increased (3) What are the creative ways or measures you can think peer group support, family support, and community support of to improve the interventions components? were viewed as beneficial elements to reduce distress of (4) How do we overcome these challenges to promote abused victims. Forinstance, supportgroup that reduces intervention programs in accordance with Chinese social isolation and further informs seniors of their rights cultural and linguistic contexts? may be helpful to victims. As one participant described, 4 Journal of Aging Research Table 1: Characteristics of the study population by the presence of step. Many participants held favorable views toward interven- elder abuse. tions delivered by community-based social services organi- zations. Community-based organizations that offer bilingual Yes No Any abuse and bicultural services have been viewed as a safe haven by (𝑁=11 ) (𝑁=26 ) immigrant older adults and perceived as the only available Age group, number (%) help resource for immigrants [5–7]. Participants perceived 60–69 5 (45.5) 8 (30.8) the easy access, prompt response, and flexibility to integrate 70–79 6 (54.5) 12 (46.2) interventions into existing programs as a plus to community- based intervention module. Advocacy and psychological 80+ 0 (0.0) 6 (23.1) intervention garnered least favorable views from our data Sex, number (%) analysis. Men 7 (63.6) 9(34.6 ) Women 4 (36.4) 17 ( 65.4) 3.3. Similarities and Dier ff ences on Perceptions of Interven- Education levels, years (%) tion Component between Victims and Nonvictims Groups. In 0–8 years 4 (36.4) 12 (46.2) addition, this study investigated the similarities and differ- 9–12 years 3 (27.3) 9 (34.6) ences regarding preferences on the intervention components 13 or more 4 (36.4) 5 (19.2) between the victims and nonvictims (Table 3). The majority of Marital status, number (%) responses on preferred intervention programs from victims fell into community-based interventions and empowerment, Married 8 (72.7) 19 (73.1) whereas for nonvictim respondents, empowerment, and Single 1 (9.1) 0 social support components received the most favorable views. Widowed 2 (18.2) 7 (26.9) Psychological interventions, including behavioral interven- Number of people in the household, tions and behavioral activations, remained least favorable by number (%) both groups. 13(27.3)6(23.1) 2-3 7 (63.6) 14 (53.8) 3.4. Perceived Challenges to Each Intervention Component. 4 or more 1 (9.1) 5 (19.2 ) This study also captured the potential challenges in the Origin, number (%) design of interventions from the perspectives of older adults Mainland 11 (100) 25 (96.2 ) (Table 4). A most commonly perceived challenge to advocacy pertains to the fear of limited actions. Participants expressed Hong Kong 0 0 that advocacy programs would not be effective if the design Taiwan 0 1 (3.8) and implementation only set out to enhance victim self- Others 0 0 care without actionable goals. Advocacy could easily be Number of years in the U.S., number interpreted as “knowledge” or “a type of explanation to (%) abusive situations” and thus may be rendered less effective. 1–10 3 (27.3) 6 (23.1) Furthermore, participants were aware of the potential imple- 11–20 2 (18.2) 7 (26.9) mentation barriers to other programs, such as empowerment 21–30 5 (45.5) 10 (38.5) and psychological interventions. Participants commented that empowerment programs would only be helpful if linking 31 or more 1 (9.1) 3 (11.5) with other elements, such as counseling or peer group Language ability, number (%) support element, that is, “empowerment does not work; if Cantonese 8 (72.2) 17 (65.4) victims are not provided with direct counseling help (and Mandarin 2 (18.2) 2 (7.7) support), then nothing can be resolved”. English 1 (9.1) 0 (0.0) The benefits of psychological interventions to reduce psy- Toishanese 0 (0.0) 7 (26.9) chological distress of victims remained least evident through- out the discussion. We suspect that the concept of behavioral activation or cognitive behavioral therapy may be foreign to community-dwelling older adults; hence there exists limited understanding on its benefits. Participants expressed the “If you have a speaker that experienced elder abuse to come major challenge pertaining to negative perceptions on psy- in and actually talk to the elders, then elders can connect with chological interventions and behavior interventions. There someone who understands what they are going through”. may be a high level of reluctance and shame in joining such Empowerment was identified as an eeff ctive process interventions. to help individuals maximize their confidence, skills, and Last, many seniors perceive intervention as a way abilities in order to regain control of their lives. Many to advocate for victims and their family members that participants perceived education as the rfi st step to inform “the community has to do something about it to pro- victims of their rights. In addition, participants also pointed vide them (victims) the protection and care that they to increased na fi ncial independence of victims as an initial deserve”. Journal of Aging Research 5 Table 2: Perceived eeff ctiveness of elder abuse intervention. Themes Subthemes Representative statements “I think you can have increased support from victims themselves, like support group type of things. If you have a speaker that experienced elder abuse to Peer group support come in and actually talk to the elders, then elders can connect with someone who understands what they are going through. eTh speaker can share his help-seeking experiences and provide guidance to other peers too.” “As family friends and relatives, we need to be patient and listen to their Family support problems.” Social support “eTh y need family and relatives to lend ears to hear their problems.” “(...) we need to get a support group together in the community centers. Before older adults realize any potential abusive situations, they can go to the support groups and let professionals intervene at the earliest possibility. Then Community support perhaps we can prevent abuse from happening.” “I was thinking that maybe there should be a place for those elders to enjoy the time or to talk about their problems with people there to help.” Phone calls and hotlines “I hope there is a bilingual hotline number to call, if anything comes up.” “Education is the first step. They (victims) need to have a clear understanding of what elder abuse is so that they know what is going on.” Education “If everyone conforms to Chinese traditional values to respect seniors, there would be no abuse at all. Therefore, education is important. If we educate everyone, then we can stop abuse.” “Counseling is important too, so that victims can talk freely about their Empowerment distress and frustrations.” Counseling “I think if a senior is abused, he/she will be very sad and painful. If we don’t provide counseling help,wewill notbeabletorelatetothattypeofturmoil and provide solutions. So I think counseling will be really critical.” “We need to improve the financial situations of abused seniors. If they can Enhance financial stand on their own feet financially, it may help them overcome abusive independence situations and decrease their risks to be victimized.” “I think the options we have may all be effective. But if I must pick one, I would Interventions delivered think community-based intervention would work best in our community, through community since seniors always turn to community social services agencies for help.” agencies “I think the community-based intervention model would work. If seniors Community- have problems, community organizations can always step in and help.” based “I think we should educate homemakers about elder abuse. On the one hand, intervention Integrate services to they can help us communicate and outreach to seniors. On the other hand, if existing social service they encounter any clients who may be victimized by abuse, they can help agencies report the cases. Homemakers should be more aware of these types of issues and advocate for seniors.” “We need to provide seniors with viable solutions. This could be one of the Understand current most important methods. Make sure the seniors are willing to listen. Advocacy situation and identify Newspapers and advertisement may be important as ways to advocate for potential solutions their rights. And provide them with potential solutions and ways out of the abusive relationships.” “It is important do something positive to alleviate their distress. For instance, I Psychological Behavior activation like painting. If I am distressed or frustrated, I would paint. It helps express intervention my feelings and frustrations. These types of changes may help victims as well.” 3.5. Strategies to Culturally Adapt Elder Abuse Interventions help seniors”. eTh importance of educating and nurturing in Chinese Communities. In light of the perceived challenges filial piety values was echoed throughout the discussions. in the design of interventions, we also solicited ways to In addition, our analysis showed that improved peer adapt existing elder abuse interventions for Chinese seniors support by organizing community social events and activities in accordance with Chinese cultural and linguistic charac- may be a viable option to increase cultural sensitivity of inter- teristics (Table 5). Most of the responses fell in the category vention programs. One participant proposed that support of improving filial piety practice as a way to improve social group discussions may be integrated with existing cultural support. As one participant claimed, “Parents will feel much programs oer ff ed by community centers. Participants also better if their children are filial. This is the best measure to called for more research and educational outreach eoff rts 6 Journal of Aging Research Table 3: Similarities and differences on perceived preferences of intervention components between victims and nonvictims groups. Proportion of Proportion of Among victims Among nonvictims responses responses Community-based 31.5% Empowerment 32.3% intervention Empowerment 31.5% Social support 27.9% Community based Social support 22.2% 22% intervention Advocacy 9.3% Advocacy 8.8% Psychological 5.5% Psychological 8.8% Table 4: Perceived challenges in the design of intervention. Themes Subthemes Representative statements “I think advocacy is not going to be useful unless you help seniors to take real actions. You need actual changes to stop abuse, not only advocating for the Advocacy will be helpful rights of seniors.” if linking to actual “Among all the components, I think advocacy is least actions to stop abuse useful. Advocacy is only knowledge, a type of Advocacy explanationtotellpeoplewhattodo. It is toofar reached and actual impact is unclear.” “We should think about the abuser. Why are they eTh root of theissueisto abusing the elderly? Maybe the abusers have some stop abusers problems or stress management issues; we should also talk to them and see how they feel.” “Empowering seniors is an added value to the intervention. It does not help solve the real problem.” Empowerment will be “Empowerment does not work. If victims were not Empowerment helpful if linked with provided with counseling...(and support), nothing counseling can be resolved. Victims will still feel lonely and frustrated.” “Some people don’t even want your help, they would be like,goaway, Idon’t need it,it’sgoing to make my The concept may be life worse for me...that’s what older people might foreign to community Psychological think...Are they going to accept that? If they go to seniors and hence intervention therapy, they may say that they don’t think they have decrease thechanceof any problems. Older people have that attitude. So using this intervention how are you going to persuade them to go to therapy and change any types of behaviors?” Health surveys were perceived as a helpful way to equip similar between victim and nonvictims. Strategies to tailor older adults with necessary health sciences knowledge. In interventions toward Chinese cultural beliefs were also pro- addition, rigorous research contributes to the identification posed with respect to nurturing filial piety values, familial of seniors at high risks of abuse as well as those “who need the integration, and improving independence of victims. most help from us”. Last, increasing religious involvement was This qualitative investigation provides new insights on recognized as a helpful strategy. Participants linked religious how minority older adults viewed different abuse interven- attendance with increased social support, and thus it may be tion components and strategies to overcome intervention an eecti ff ve intervention for victims. barriers. First, our ndin fi gs provide direction for violence- related intervention services. A multidisciplinary approach that includes strengthening the informal support system 4. Discussion including family members, friends, and community gate- keepers as well as facilitating access to formal services In this first exploratory study of perceived effectiveness, building on the health care system warrants exploration in challenges, and cultural adaptations of elder abuse inter- this context. ventions among community-dwelling Chinese older adults, It has been argued that older adults with fewer psychoso- our ndin fi gs suggest that older adults viewed social support, cial resources or more psychosocial deficits seem to be more empowerment, and community-based interventions design vulnerable to elder abuse, and elder abuse seems particularly as most effective to vulnerable victims. The preferences were Journal of Aging Research 7 Table 5: Strategies to culturally adapt elder abuse interventions in the chinese communities. Themes Subthemes Representative statements “Parents will feel much better if their children are filial. This is the best way to help seniors. Much better than improving other types of social support. So we need to educate our children and grandchildren and try to avoid family Improve and nurture conflicts.” filial piety “Abusive situations can be much improved upon if children are filial. If they respect seniors, they will feel much better. Wouldn’t you say that this is the best way to improve the mental health of victims?” Improve social support “We can organize more social events and activities for older adults. I think Chinese seniors are oeft n lonely. Especially those who may encounter problems and conflicts at home. If we can get them to go to those support groups, it will help ease their minds.” Improve peer support “Seniors need to make more friends, especially with those who are currently undergoing similar issues. We need to get Chinese victims all together, like having them go to the same group discussion in community centers aer ft some sort of painting classes or tai-chi classes.” “eTh U.S. government should be attentive of the social welfare needs of Provide financial Enhance victims’ immigrant older adults. I think if abused seniors have more financial means, independence financial independence or financially more stable, they may not need to depend on the abusers at all, which will help improve their independence.” “We need to organize more educational workshops and group activities. It will be helpful if seniors are educated and informed of the benefits to Provide education interventions.” Research through research and “We need more research and health surveys that gather comprehensive health workshops information of seniors. We will be able to document the health and well-being of seniors this way and reach out to those who need the most help from us.” “I believe we can try to help them by increasing their religion involvement. If Provide victims with Religion they have higher religious attendance, they may be able to get more social religious support support as well.” detrimental to psychological well-being for victims [34]. Our future research is needed to move forward to designing data suggest that the increased social support from family, multicomponent elements of interventions suitable for the friends, and supports is viewed as amongst the most eeff ctive needs of minority older adults. For instance, studies in tribal interventions in increasing psychosocial resources of victims. communities found that interventions that oeff r combina- This ndin fi g resonates with respect to important Chinese tionsofindividualorfamilycounseling, case management, traditional values of filial obligations of respect and care from skills training, and behavior management strategies may be older adults. Despite acculturation challenges brought about more effective than interventions that only provide a peer by immigration, many traditional values and practices are support group [37]. Measures that provide the opportunity still entrenched in this community. eTh utilization of family for older adults, caregivers, families, and health professionals power in intervention designs warrants further attention. to come together to prevent and mitigate elder abuse in a It is also worth noting that advocacy and psychological community setting may be a novel option for Chinese older interventions received limited appraisal among participants. adults. Advocacy programs aim to enhance abused victims’ self- Furthermore, the results highlight the need to alleviate care by helping them to make sense of the situation, identify older adults’ fears and shame in disclosing abuse. Our nd- fi potential solutions, and achieve the goals they have set ings reveal that there exist more similarities than differences [24]. From the limited empirical evidence, the effect of in the preferences of intervention programs between suscep- advocacy intervention designed to improve quality of life tiblevictims andnonvictims. Although thefindingmay be and mental health of Chinese abused women remained to duetoasmallsamplesizeeeff ct,the violence andmental be seen [14–16]. Similarly, whereas cognitive behavior model health stigma may indeed aeff ct older adults’ willingness to remained less favorable, some researches suggest that it can enroll in intervention programs. Health care providers should be a viable model in Chinese American population, with consider outreach programs particularly designed to reduce afew modicfi ations [ 35, 36]. Systematic research is needed the stigma of violence and caregiver stress among Chinese to explore the eeff ctiveness of the different components of immigrant families. the advocacy and psychological intervention for the various Last, conducting participatory research approach allows forms of elder abuse. us to prioritize sensitive cultural context and increase the In addition, given that community-based intervention relevance of our research n fi dings to actionable interven- module is appraised by Chinese older adults in this study, tion goals [38, 39]. When culture is continually evolving, 8 Journal of Aging Research the ability to identify factors that are amendable to adaptation [2] S. R. Beach, R. Schulz, N. G. Castle, and J. Rosen, “Finan- cial exploitation and psychological mistreatment among older to theChinese population wouldhelpensurethatthe health adults: differences between African Americans and non-African intervention is sensitive to the needs and concerns of victims. 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