Relationship between the levels of family burden in caring for older people with the incidence of mistreatment

Abstract

Background

Caring for older people can be a burden for the family that led to mistreatment.

Objective

To determine the relationship between the levels of family burden in caring for older people with the occurrence of mistreatment incidence. Design and participants: A cross sectional study design was conducted with 135 older people who live with their family as respondents.

Setting

135 families with older people at Kelurahan/Village of Harjamukti area, Kecamatan/ District of Cimanggis, Depok city.

Method

This study applied probability sampling technique with multistage cluster sampling.

Results

Family characteristics show that almost half of older people were caring by family members (caregivers) who were aged 20-39 years, nearly all caregivers were women, family income mostly less than UMK, families mostly monosyllabic nation Betawi and caregivers mostly were their own child. Most of the families stated that no expense in caring for the older people (89.6%), but there are still families who feel the burden of caring. The highest type of mistreatmet of the older people is psychological mistreatments.

Conclusions

From the statistical test obtained by p value equals to 0.553, it was concluded there was no correlation between the incidences of any family burden with mistreatment.

Introduction

One area will be called as an old structure area if the percentage of older people in it is more than 7%. BPS RI-SUSENAS 2009, in Komisi Nasional Lansia, states that the average percentage of older people residents in Indonesia at 8.37%, so that Indonesia is one of old structured nation. Among 34 provinces in Indonesia, there are 11 provinces that have older people population more than 7%. Three provinces with highest percentage are Daerah Istimewa Yogyakarta (14.02%), Jawa Tengah (10.99%), Jawa Timur (10.92%), while three provinces with the lowest percentage of older people are Papua (2.16%), Papua Barat (3.31%), and Kepulauan Riau (4.83%). BPS RI, in Older People Population Profile compiled by Komisi Nasional Lansia in 2010 explained that West Java is one of old structured province since population of older people in West Java is 7.95% of the total population of 41 902 385 inhabitants^1,2.

Older people experience changes due to aging process; one of aging process is a biological change. Physical changes affect older people’s body condition, for example muscle atrophy, loss of elasticity in blood vessels, increased blood pressure, decreased saliva production, and changes in urinary patterns. According to Miller’s theory, theory of Consequences, the health problems in the older people may occur due to a variety of biological changes in the older people. The health problems become increasingly severe because it is accompanied by risk factors, such as diet pattern since a young age and less supportive lifestyle³.

Older people as family member adopt healthy behaviors which the family has believed in. Family actually is the first environment to establish healthy behaviors and habits include the value of healthy lifestyle as well as perceptions of health risks. It means family behaviors have big impact to the health status of older people. Furthermore, family supports to older people can affect older people level of dependency. If family support is inadequate, it may cause high level of older people dependency toward the family.

The family as the closest relative to older people needs to have ability to fulfil the elders’ basic needs. Mistreatment can happen if the family fails to provide a good care for elders. Caring for older people can be a burden for the family that led to the mistreatment. Research conducted by Galuh, Caregiver Burden dan Strategi Coping pada Family Caregiver, using qualitative methods states that caregivers of people with HIV / AIDS experience the burden in the patient care process. The burden appears in the form of a physical burden, financial, social, and economic⁴.

Family is also the closest one who directly provides care for older people. Mistreatment may occur when there is a high dependency of elders; family ability is not effective in providing care for elders; and burden feeling from family. Some people believe that mistreatment can be associated with revenge from children who experience violence from parents⁵.

National Center on Elder Abuse, USA states that neglect of older people is one of the mistreatment to older people. Duckhorn also describes types of mistreatment of older people such as 14.6% physical mistreatment, 12.4% of financial mistreatment, 7.8% of emotions mistreatment, 0.4% of sexual mistreatment, 55.1% neglect of the older people, 4.1% unknown and 6.2% happen other mistreatments. Research conducted by Rekawati found that older people who often have mistreatment in this study are aged 60-75 years old, female, Javanese tribe, Moslems, only completed elementary school, and a widow or widower^6–8. It was also identified that incidence of mistreatment to older people who live with their family was increasing every year.

There were so many research related to older people has been done in Indonesia at this time, especially research related to mistreatment incidence toward infants up to older people. However, there was no research on the perceived burden of families who provide care for older people that influences mistreatment. Based on this condition, researcher interested to explore the relationship between levels of family burden in caring with the incidence of mistreatment of older people.

Method

This quantitative research design was performed with simple descriptive design applied with cross-sectional study approach (cross-sectional). Samples of this research are determined by the formula according to Lemeshow⁹ and amounted to 135 people. Inclusion criterias for this study consist of two categories, namely the older people and families. Older people inclusion criterias include: age over 60 years, staying with family, be able to perform verbal communication effectively, minimal educational level is elementary school, and was will-ing to be the subject of research. While the inclusion criterias for the family or caregiver is: stay with older people, be able to perform verbal communication effectively, minimal education level was high school graduation, and was willing to be the subject of research.

Research was conducted using probability sampling technique with multistage cluster sampling. This technique used to determine the sample when the source data is very broad. Before collecting data, the researchers conducted tests on the instruments used in the Kelurahan Cisalak Pasar area. Kelurahan Cisalak Pasar has similar characteristics with the population of research target area. Processing and data analysis was performed using the computer program and calculating with the help of statistical tests to determine the frequency distribution and proportion of each variable. Research conducted at Kelurahan Harjamukti Kecamatan Cimanggis of Depok. Prior to the implementation of the study, respondents got explanation of the purpose and benefits of research and were requested approval by completing the informed consent.

Results

Table 1 shows the characteristics of the older people mostly aged between 60-69 years, the majority of respondents are female, almost entirely under UMK income. Table 2 shows almost half of older people cared by family members (caregivers) were aged 20-39 years, the majority caregiver is female, most of the family income is less than UMK, and the caregivers mostly the elders’ child.

Table 1.

Characteristics of older people, Kelurahan Harjamukti Kecamatan Cimanggis (n = 135).

No.	Characteristics	Amount	Percentage (%)
1	Ages
	60-69 years old	69	51.1
	70-79 years old	42	31.1
	≥ 80 years old	24	17.8
	Total	135	100
2	Gender
	Women	75	55.6
	Men	60	44.4
	Total	135	100
3	Income
	< UMK	124	91.9
	≥ UMK	11	8.1
	Total	135	100
4	Etnics
	Betawi descent	77	57.0
	Sundanese	55	18.5
	Javanese	29	21.5
	Others	4	3.0
	Total	135	100

Table 2.

Characteristics of families, Kelurahan Harjamukti Kecamatan Cimanggis (n = 135).

No.	Characteristics	Amount	Percentage (%)
1	Age
	≤ 19 years old	1	0.7
	20-39 years old	79	58.5
	40-59 years old	51	37.8
	≥ 60 years old	4	3.0
	Total	135	100
2	Gender
	Women	119	88.1
	Men	16	11.9
	Total	135	100
3	Income
	< UMK	103	76.3
	≥ UMK	32	23.7
	Total	135	100
4	Etnics
	Betawi descent	83	61.5
	Sundanese	22	16.3
	Javanese	27	20.0
	Others	3	2.2
	Total	135	100
5	Family relationship with older people
	Child	90	66.7
	Daughter in law	22	16.3
	Couple	15	11.2
	Grandchildren	6	4.4
	Brother/sister/niece	2	1.4
	Total	135	100

Table 3 shows the majority of families stated having no burden of caring for older people (89.6%), but there are families who feel the burden of caring for older people. Table 4 shows the highest type of mistreatment of the older people is psychological mistreatment.

Table 3.

Family burdens in caring for older people, Kelurahan Harjamukti Kecamatan Cimanggis (n = 135).

No.	Level of family burden	Amount	Percentage (%)
1	No burden	121	89.6
2	Burden	14	10.4
	Total	135	100

Table 4.

Incident of older people mistreatment in families, Kelurahan Harjamukti Kecamatan Cimanggis (n = 135).

No.	Mistreatments	Amount	Percentage (%)
1	Mistreatments
	No	68	50.4
	Yes	67	49.6
	Total	135	100
2	Physics Mistreatments
	No	102	75.6
	Yes	33	24.4
	Total	135	100
3	Financial mistreatments
	No	74	54.8
	Yes	61	45.2
	Total	135	100
4	Psychological mistreatments
	No	34	25.2
	Yes	101	74.8
	Total	135	100
5	Neglect
	No	76	56.3
	Yes	59	43.7
	Total	135	100

Table 5 illustrates the burden of the family relationship with the incidence of mistreatment of the older people. Older persons who were caring by families with burden experienced mistreatment (57.1%). However there were still many older persons (48.8%) who also experienced mistreatment although their families have no burden. From the statistical test obtained by value p = 0.553, it was concluded there was no correlation between the incidence of the burden on families with mistreatment toward older people.

Table 5.

Relationship between family burdens with the incidence of mistreatment, Kelurahan Harjamukti Kecamatan Cimanggis (n = 135).

Family burdens	Mistreatment				Total		p value	OR (95%CI)
	No		Yes
	n	%	n	%	n	%
No burden	62	51.2	59	48.8	121	100	0.553	1.401 (0.459-4.281)
Burden	6	42.9	8	57.1	14	100
Total	78	50.4	67	49.6	135	100

Discussion

In this study, it was found that the family will always taking care of their elders and tend to not hand over caring responsibility to others. The family also stated that they will continue to provide better care for their elder. This statement was contradicts to other research which was conducted by Kurasawa. He found that dementia and its behavioral were the main factors that lead to higher levels of burden for caring older people. Then at the same time, it became the main factor which encourages families to hand over older people care to health institutions. In accordance with the theory of consequences Miller that the heavier the level of dependency of the older people, the heavier the burden load experienced by the caregivers^3,10. It means the caregivers or in this case the families must able to adapt to the personality and behavioral changes which experienced by older people.

Other studies related to the burden of caregivers in caring for older people conducted by Matsumoto et al.¹¹ with the aim to evaluate caregiver burden associated with Behavioral and Psychological Symptoms of Dementia (BPSD). This study can be concluded that burden associated with BPSD different for each symptom and not always depended on frequency and severity of BPSD. These findings suggest that some symptoms, such as agitation/aggression and irritability/lability, can affect the caregiver significantly, although the frequency and severity of BPSD are low. The burden of caregivers can cause depression and lead to mistreatment. Therefore, burden of caring older people is a social problem and it is important to be indicated as an indication of mistreatment incidence.

Results of this study along with Sahar’s research. It found Family Careers Training Program (FCTP) can reduce family burden in providing care significantly in the intervention group than the control group¹². This research has two similarities with Sahar’s research. Firstly is the usage of similar approach to train the caregivers about caring older people at home appropriately. Secondly is the research’s focus. The focus of this research is follow-up care evaluation monthly through home visits.

However, this research has some differences too. The differences are the duration of research implementation and instrument which was applied. Even though, these researches have different duration time implemention, but they have the similar result. The result is caregivers’ burden in caring older people is decreased after receiving intervention. Instruments which used in Sahar’s research is Screening for Caregiver Burder (CBS), whereas this research use The Zarit Burden Interview (ZBI). Although using different instruments, the two instruments provide the similar information related to caregivers’ burden in caring older people.

The result of this research also supported by another research. Riasmini found that burden of caring older people decreased significantly at three months and six months after the intervention of Independen Family Group Model. Riasmini’s research was provided a training to caregivers then continued with group meeting every two weeks with assistance periode for three months and independent periode for three months after assistance periode. Monitoring carried out in the first three months through home visits and group meetings. While nursing model “Santun Lansia” focuses on families’ empowerment in caring for older people. Group activities undertaken aimed to provide sharing experiences in caring for older people¹³.

The information related to the feelings of caregivers in caring for older people was also obtained in this research. Families and caregivers stated that older people is a figure that should be appreciated, respected and upheld. The role and position of older people in the family and society is strongly influenced by cultural perspectives regarding older people. Different perspectives of the older people would make different attitude and respect for older people in the family and society. Statement of caregivers who stated that there is no burden of caring older people needs to be sharpened with other measuring devices due to the possibility of a not necessarily objective statement. This is possible to happen because of Indonesia’s culture as well as other factors that cause less open caregivers associated with their feelings for caring for older people.

According to Swasono, various cultural lives are establised old age, role and social function to have different values, assumptions, and sizes. However, there is a universal perspective that older person is considered as a source of accumulation of wisdom and discernment¹⁴. Thus, older people population is considered to have more aptitudes, specific espertises, and experiences, so that they must be respected. In the traditional society which generally consists of a large family, entering old age does not need to be worried. Older people in traditional society have the best social security, in which their children and their other relatives. Children of older people still feel obliged and have tendency to give some money to their parents who can no longer take care of theirselves. There is a valid value in the society that says the child is obliged to give affection to his parents as ever they got when they were young. These things are exactly what make a family or caregivers feel does not have any burden of caring for t older people.

In this research, there are differences in the characteristics of ethnic families in the intervention group and the control group. Some families in the intervention group were Betawi descents in the control group while the majority ethnic of control group is Javanese. In Indonesia, almost all ethnic groups have the same perspective about the figure of older people, the older people as someone who should be respected and upheld his dignity. So, the ethnic diversity perspectives toward older people in Indonesia have no difference.

In Mongolian community in Onon there is one statement “Honor and wealth given to ordinary people; however, the ripe old age is a gift of heaven”¹⁵. Based on this, no one is trying to hide his or her old age. Moreover, everyone expects periods in which they become older people then receive the respect and appreciation. Japanese society is known as a large number of older people (Super Aged Society). Japan as Japanese’s country is a country that still respects the older people as people who should be respected and upheld. Their respect to older people is shown by how the Japanese tried to provide facilities and excellent health care for older people. We can easily find in almost every public facility in Japan, ranging from shopping centers, exhibition of paintings, tourist attractions and even public libraries. Japan provides special facilities for older people and disabled people to enable them to use the facility, for example, is on public transportation such as buses and trains, we can see the priority seats for the older people and disabled are being used properly. Older people in Japan can work like everyone; they still socialize with each other and look energetic.

Another study which conducted by Muraki et al.¹⁶ about the relationship patients suffering from stroke and dementia with family caregivers’ burden in the general population of Japan. The conclusion shows that the burden of family caregivers’s of stroke patient is higher than the burden of family caregivers’ of dementia patient. Compared with patients who suffer from dementia, stroke condition not associated with increased caregiver burden further. The difference between Muraki’s research and this research is the level of dependence of the respondents, the higher level older people’s dependence, the bigger burden caregivers perceived³. The similarity between Muraki’s research and this research is using the same instrument to identify the burden of caregivers by using The Zarit Caregiver Burden Interview which can be used with varying degrees of dependence.