Downloaded from http://bmjopen.bmj.com/ on December 20, 2016 - Published by group.bmj.com Open Access Protocol Elder mistreatment in a community dwelling population: the Malaysian Elder Mistreatment Project (MAESTRO) cohort study protocol Wan Yuen Choo,1 Noran Naqiah Hairi,1 Rajini Sooryanarayana,1 Raudah Mohd Yunus,1 Farizah Mohd Hairi,1 Norliana Ismail,1 Shathanapriya Kandiben,1 Zainudin Mohd Ali,2 Sharifah Nor Ahmad,2 Inayah Abdul Razak,2 Sajaratulnisah Othman,3 Maw Pin Tan,4 Fadzilah Hanum Mohd Mydin,3 Devi Peramalah,1 Patricia Brownell,5 Awang Bulgiba1 To cite: Choo WY, Hairi NN, ABSTRACT et al Strengths and limitations of this study Sooryanarayana R, . Introduction: Despite being now recognised as a Elder mistreatment in a global health concern, there is still an inadequate ▪ community dwelling This study is among the first few cohort studies amount of research into elder mistreatment, especially population: the Malaysian investigating into elder mistreatment in the South Elder Mistreatment Project in low and middle-income regions. The purpose of this East Asian region. (MAESTRO) cohort study paper is to report on the design and methodology of a ▪ It has a prospective study design with a long protocol. BMJ Open 2016;6: population-based cohort study on elder mistreatment period of follow-up, with emphasis not only on e011057. doi:10.1136/ among the older Malaysian population. The study aims epidemiological characteristics of elder mistreat- bmjopen-2016-011057 at gathering data and evidence to estimate the ment but also on determinants at different levels prevalence and incidence of elder mistreatment, of framework and measuring consequences of ▸ Prepublication history for identify its individual, familial and social determinants, abuse. this paper is available online. and quantify its health consequences. ▪ The study subjects are representative of the older To view these files please Methods and analysis: This is a community-based rural Malaysian population as the sampling frame visit the journal online prospective cohort study using randomly selected is derived from the national census. (http://dx.doi.org/10.1136/ households from the national census. A multistage ▪ Face-to-face interviews and active engagement of bmjopen-2016-011057). sampling method was employed to obtain a total of local community with personalised contact were 2496 older adults living in the rural Kuala Pilah district. Received 6 January 2016 employed to ensure a high response rate. ▪ Revised 13 April 2016 The study is divided into two phases: cross-sectional Exclusion of groups most at risk of elder mis- Accepted 3 May 2016 study (baseline), and a longitudinal follow-up study at treatment, in particular, older adults with demen- the third and fifth years. Elder mistreatment was tia, those with severe cognitive impairment and measured using instrument derived from the previous elders residing in long-term care institutions, literature and modified Conflict Tactic Scales. may potentially under-report the abuse Outcomes of elder mistreatment include mortality, estimates. physical function, mental health, quality of life and health utilisation. Logistic regression models are used to examine the relationship between risk factors and departments, and published in appropriate scientific abuse estimates. Cox proportional hazard journals and presented at conferences. regression will be used to estimate risk of mortality associated with abuse. Associated annual rate of hospitalisation and health visit frequency, and reporting of abuse, will be estimated using Poisson regression. INTRODUCTION Ethics and dissemination: The study has been The publication, ‘Granny Bashing’, in 1975, approved by the Medical Ethics Committee of the is generally regarded as the starting point for University of Malaya Medical Center (MEC Ref 902.2) 12 For numbered affiliations see and the Malaysian National Medical Research Register systematic research into elder abuse. More end of article. (NMRR-12-1444-11726). Written consent was recently, there has been an expanding move- obtained from all respondents prior to baseline ment to improve rights of the elderly, and Correspondence to assessment and subsequent follow-up. Findings will be their physical and emotional well-being. The Dr Wan Yuen Choo; disseminated to local stakeholders via forums with WHO has recognised elder mistreatment [email protected] community leaders, and health and social welfare (also known as elder abuse and neglect) as a Choo WY, et al. BMJ Open 2016;6:e011057. doi:10.1136/bmjopen-2016-011057 1 Downloaded from http://bmjopen.bmj.com/ on December 20, 2016 - Published by group.bmj.com Open Access growing challenge in the field of public health, and pervasiveness and lack of awareness on elder mistreat- social and criminal justice worldwide. Elder mistreat- ment in the community.17 One of the earliest attempts ment is defined as ‘a single or repeated act, or lack of to quantify the elder mistreatment issue among older appropriate action, occurring within any relationship Asian populations was conducted by Dong and collea- where there is an expectation of trust which causes gues, who performed a cross-sectional survey among harm or distress to an elder person’. This includes detri- older Chinese adults in a medical centre in Nanjing, ment to older adults by people they know or with whom China. They found about 35% of elderly screened posi- they have a relationship, such as spouse, partner or tive for elder mistreatment with neglect found to be other family member, friend or neighbour, or those on most common form of abuse, followed by financial whom they rely for services.3 Elder mistreatment is exploitation and psychological abuse.18 Epidemiological broadly categorised into physical, psychological or emo- evidence on elder mistreatment in this region remains tional, financial, sexual and neglect.4 to be found. Further research to determine the extent Research findings in economically developed regions of elder mistreatment and the universality of its risk and circumstantial evidence suggest that elder mistreat- factors across different populations is necessary. ment is a much more universal phenomenon than what Empirical data are essential to identify older adults at is generally perceived by society. Elder mistreatment risk and facilitate the development of community- prevalence estimates documented by recent studies specific and evidence-based preventive measures. varied from as low as 1.1% to as high as 44.6%,5 while Malaysia is a multiethnic and multicultural country Cooper and colleagues in an earlier review found that with a population estimate of 29 million in 2014. older population studies generated a prevalence esti- According to the World Bank classification, Malaysia is mate of between 3.2% and 27.5%. Dependent or vulner- an upper-middle-income and developing economy situ- able older people are at higher risk of abuse with nearly ated in the East Asia and Pacific region.19 Its population a quarter of them reporting psychological abuse and a consists mainly of ethnic Malays (47%), followed by fifth reporting neglect.6 Early studies of elder mistreat- Chinese (25%), Indians (7%) and indigenous tribal ment derived from Western countries indicated an asso- groups (11%). Population projections predict that the ciation between abuse and gender, socioeconomic status number of people aged 60 years and above will form – and ethnicity.7 9 For instance, older women were more nearly 11% of the national population by 2020, and this likely to experience abuse, but this differed according to figure will double by 2040.20 This substantial increase in the type of abuse.7 Older adults with cognitive and func- the older populace, along with rapid urbanisation and tional impairment, dementia, disabilities and other changing family structures, will bring about greater chal- chronic health problems are particularly at risk of abuse lenges to the provision of care for the older person. As – due to increased dependence on caregivers.10 12 in many Asian countries, most older Malaysians rely Caregivers’ psychiatric disorders, previous history of vic- heavily on their children for care and financial support. timisation, poor social support, substance use, high This is especially customary among elders living in rural levels of hostility, and their dependence on the victim areas, where there is an inadequate pension and social for accommodation as well as financially, also appear to support system, and limited access to medical care, as – be associated with elder mistreatment.11 13 15 Others compared to what is enjoyed by their more affluent reported shared living arrangement, social isolation, urban counterparts. The rural–urban migration of loneliness and caregiver strain as risk factors.13 16 youths in search of better job opportunities has also The ‘mapping’ of elder mistreatment occurrences, greatly weakened the family’s perceived obligation of and understanding of their risk factors and health con- caring for their elder members. The lack of a social sequences across cultures, have been significantly safety net coupled with heavy reliance on their children limited by the narrow geographical base of current expose the rural older population to a greater likelihood research, with most being conducted in economically of abuse and exploitation. developed countries. This distinct gap in the existing lit- A number of countries have enacted statutes for erature is reflected by the paucity of robust studies on reporting elder mistreatment