Poor Financial Support and Lack of Knowledge, and Neglect Among Female Elders Who Lived in Extended Families

Introduction: Elder neglect remains as unreported case that involved old women in Ampenan West Nusa Tenggara. Despite the paucity of evidence to report the significance, an earlier pilot study showed that elders who lived with their family in Ampenan were found dirty, skin dry, and malnourished. The purpose of this study was to explore the correlating factors to the unreported cases of neglect among these elders. Method: This study was a cross sectional conducted using analytic descriptive approach. Thirty-four extended families lived with female elders in the working area of Puskesmas Ampenan were purposively involved as participants to this study. Family's awareness of abuse was collected using a questionnaire developed based on Elder Abuse Instrument component checklist and the suspicion to neglect among the elders were collected using the 13-item checklist from Elder Abuse Instrument. The data were then analyzed using Spearman's rho (α ≤ 0,05). Result: The results show that family's lack of knowledge has a strong correlation with elder neglect (p= 0,000 with r= 0,643). Discussion: The analysis to this finding suggests that not only were the families lack of knowledge, but they were also being burden by the poor economic situation that trigger the unnecessary neglect to their female elders. These results abridge the paucity of evidence to explain the correlating factors with the incidence of elder abuse in eastern Indonesia. Further research is necessary to explain the size and the impact of neglect toward the elders. It is suggested that local department of health, Puskesmas and health professionals to educate the community as the first step to improve the elders' quality of life and promote healthy ageing.


INTRODUCTION
Neglect is one of the most common family mistreatment towards elder (Alizadeh-Khoei et al. 2014). Neglect can be defined as intentional or unitentional failure in providing the basic care for the elder (Maurier & Smith 2005). This definition also refers to self and FDUHU ¶V failure in providing proper food, physical and psychological isolation, leaving the elder to stay on damp clothing, or other harmful situation Poor hygiene, having skin problems, malnourished, and living in a filthy are the major indicators for a neglect (Elder Abuse Prevention Unit 2014).
The World Health Organization (2015) confirms that most of the cases occurred in extended families and were misdiagnosed. The Bureau of Justice Statistics (2012) reported that in The United States about 2.2 million cases of mistreatment reported anually. About 67.3% of the victims were female (National Center on Elder Abuse 2015). Similarly, the cases also occurred in Spain. Marmolejo (2008) reported that the victims were mostly female elders. The fact that they could live longer, financially more dependent, and more prone from chronic diseases (when compared with the opposite gender) have made them vulnerable as victims of abuse (Anetzberger 2012).
Earlier studies added advanced aged, dependency, interfamilial conflict, depression, isolation, and poor health as main factors that contribute to neglect (Alizadeh-Khoei et al. 2014;Begley & Matthews 2010;Maryam et al. 2012). Furthermore, burdended stress in providing care for all the members, and economical situation of the family also triggers the mistreatment to the elders (Maurier & Smith 2005). In addition, neglect could be a result IURP WKH FDUHJLYHUV ¶ ODFN RI DZDUHQHVV (Bureau of Justice Statistics 2012).
A pilot to this study showed that elders who lived with their family in the sub-district of Ampenan Tengah of West Nusa Tenggara were found dirty, skin dry, and malnourished. They were left-alone in their family-houses while the younger adults were working outside. Thus, this study was designed to explain further the contributors to elder neglects in the working area of Puskesmas Ampenan in West Nusa Tenggara.

METHOD
This study explored the correlations EHWZHHQ WKH VHFRQG JHQHUDWLRQ ¶V NQRZOHGJH LQ caring their female-elder and the possibility of elder neglect in families. The working area of one public health center (Puskesmas) in Mataram, the capital region of a province in the Island of Nusa Tenggara Puskesmas Ampenan was selected prior to the earlier pilot observation showed that more than thirteen female elders lived in that area were in poor condition and left alone without support at most of the day. According to the definition proposed by the Elder Abuse Prevention Unit (2014) their conditions can be considered as being neglected.
The ethical clearance of this study have been approved by the Faculty of Medicine Universitas Airlangga Ethical Committe on Health Research under the article number 442/EC/KEPK/FKUA/2016. This study used a descriptive analitical approach, a cross sectional method. Thirty-four extended families that were taking care of grandmothers and/or their female parents in law and have more than one child in a house were involved as the unit analysis. Both male and female (husbands and wifes) DGXOWV ¶ knowledge in caring elders was analyzed as independent variable, while the possibility of neglect experienced by female-older member (grand mothers) of the family as the dependent variable.

RESULTS
The demographical data on table 1 showed that most of the adults in the families were in the productive age of 25 to 45 years old. About 79% of the adult female in the families were full-time mothers who have not only taking care of their female-elder family members, but also their children. It can be asumed that the income of these families came from the husbands only. Almost all of the adult respondents have limited knowledge, reflected from their highest degree of education. The data gathered from the questionnaire-guided interviews showed that the adults ¶ XQGHUVWDQGLQJV DERXW HOGHU DEXVH were poor. Table 2 shows that only three families have enough awareness about abuse, while about 47.1% others did not know anything about abuse.
The test using EAI showed that 41.2% of the female-elders who were member to the families as responders were suspected of being unintentionally neglected. However, the test also revealed that the other 58.8% elders were not neglected (See Table 3).
7KH VWDWLVWLFDO WHVW 6SHDUPDQ ¶V 5KR revealed that DGXOWV ¶ UHIHU WR KXVEDQG DQG ZLIH knowledge about abuse corelates with the prevalence of elder neglect (p=0.001). It is also indicated that the knowledge has a strong corelation with neglect (r=0.643) (See table 4).

DISCUSSION
Education is one of supporting factors to individuals in gaining and synthesizing information. (Notoatmodjo 2007) asserts that the higher the education the more knowledge individual can get. This refers to the higher the level of education the more information individuals would gain, as well as their broad knowledge.
The results of this study imply that almost half of the involved respondents neglected their female elders. They were mostly malnourished and poor. Among the suspected FRQWULEXWRUV IDPLOLHV ¶ ODFN RI DZDUHQHVV DERXW elder neglect was identified to correlate significantly with the unreported cases. To authors ¶ RSLQLRQ SDUWLFLSDQWV ¶ ODFN RI knowledge has made them unable to identify whether they have treat their elders correctly. The UHVSRQGHQWV ¶ ODFN RI NQRZOHGJH ZDV VXVSHFWHG because of the small flow of information in Ampenan, the small village in West Nusa Tenggara, the place they lived. The Puskesmas (local public health service) in Ampenan had never involved families nor provided LQIRUPDWLRQ DERXW HOGHU ¶V KHDOWK On the other hand, there is no evidence to support that elder abuse as either important or familiar topic. Therefore, unfamiliarity of elder abuse became one major contributor to the high-prevalence of unreported neglect.
This study also suggests the poor financial support as another factor to neglect. This finding showed that most of the neglected elders lived in families with low economic status, where daily needs are often short. According to the American Psychological Association (2012) this situation could lead to family stress and triggers neglect to elders. The situation was worse for elders who lived with families where the householders do not have permanent work. The householders would have been burdened with their responsibility in providing proper living for their families with children and also for their elders. That the majority of the householders in Ampenan was unemployed and did not have permanent work, it is reasonable that elders were unnecessarily neglected.
The awareness of a family plays a major role as predisposing factor to an act of abuse (Notoatmodjo 2007). Neglected elders as subject in this study lived with families who were not aware of elder abuse. This implies a strong correlation between the unfamiliarity of abuse as health issue and the incidence of neglect. This study concludes that the lack of information resource, the insufficient effort by Puskesmas to involve families, and unemployment promotes the unreported cases of neglect in Ampenan. Furthermore, the number of neglect could continue to rise as unimportant message in eastern Indonesia. Therefore, it is suggested that local department of health, Puskesmas and health professionals to educate the community as the first step to improve WKH HOGHUV ¶ TXDOLW\ RI life and promote healthy ageing.

Conclusion
The unfamiliarity of elder abuse was highlighted as factors that correlate with neglect experienced by elders who lived in extended families. The insufficient knowledge among the adults of extended families with which the elders lived was strongly corelates with the unreported cases of neglect. The poor and burden of economic wellfare in Ampenan are also correlate with the unnecessary acts of abuse by families. These results add to the available evidence found in earlier studies and theories. However, this study did not explain about the size of the abuse and how big was the impact of neglect toward the elders. These results abridges the paucity of evidence to explain the correlating factors to the incidence of elder abuse in eastern Indonesia.

Recommendation
It is suggested that local department of health, Puskesmas and health professionals to educate the community as the first step to LPSURYH WKH HOGHUV ¶ TXDOLW\ RI OLIH DQG SURPRWH healthy ageing.