被忽视的声音

被忽视的声音 从老年人们的角度来看老年人虐待问题

上海新途社区健康促进社出品 资助方：上海市福利彩票公益金

MISSING VOICES Views of older persons on elder abuse

目录 致谢

1

执行总结

3

介绍

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1. 背景

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1.1 老年人虐待的研究历史

7

1.2 老年人虐待的定义

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1.3 老年人虐待问题的影响范围

9

2. 项目

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2.1 研究目标

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2.2 研究方法

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2.3 定性资料分析：国家报告

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3. 发现和讨论 3.1 虐待的主要类型

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A) 社会结构性虐待

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B) 忽视与遗弃

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C) 对老年人的不尊敬与歧视

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D) 法律与财产虐待

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3.2 虐待的具体情境

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A) 退休老人的社会角色

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B) 长期护理机构(LTCI)

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C) 医疗护理人员作为施虐者或者受害者

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D) 具体文化差异对虐待的影响

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4. 启示——老年人虐待的预防策略

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4.1 专题小组参与者们提出的策略

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4.2 项目组的策略与行动建议

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4.3 结论——前进的道路

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参考文献 各国研究协调员

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Table of contents Acknowledgements

2

Executive summary

4

Introduction

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1. Background

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1.1 The history of elder abuse

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1.2 Definitions of elder abuse

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1.3 The scope of the problem

10

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2.1 Aims and objectives

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2.2 Research methodology

14

2.3 Qualitative data analysis: national reports

16

2. The Project

3. Findings and discussion

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A) Structural and societal abuse

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B) Neglect and abandonment

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C) Disrespect and ageist attitudes

26

D) Legal and financial abuse

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3.2 Concrete contexts of abuse

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A) Retirement and the social roles of older persons

34

B) Long-term care institutions (LTCI)

34

C) Health care professionals as abusers and as victims

36

D) Culture-specific influences on abuse

40

3.1 Key categories of abuse

4. Implications—strategies for the prevention of elder abuse

4.1 Strategies proposed by the focus groups participants

42

4.2 Strategies and recommendations for action by the project team

46

4.3 Conclusions—the way forward

References

Coordinators of the national studies

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致谢 这项研究最初由世界卫生组织老龄化与生命过程小组(WHO/ALC)协调员Alexandre Kalache博士发起，他邀请了国际老年人虐待预防网络(INPEA)与世界卫生组织合作一起发展应 对全球老年人虐待问题的方案。来自巴茨和英国伦敦玛丽皇后医学与牙医学院，任国际老年人虐 待预防网络秘书的Gerry Bennett教授成为该研究的主要负责人。WHO/ALC技术官员Silvia Perel Levin女士成为了该项目的主要联系人，设计了专题小组草案并且在Klache博士和 Bennett教授的监督下协调整个项目。加拿大麦吉尔大学的Silvia Straka女士完成了该研究的定 性分析。Gerry Bennett教授、Silvia Perel Levin女士和Silvia Straka女士撰写了这篇报告。 特别感谢这次参与阿根廷、奥地利、巴西、加拿大、印度、肯尼亚、黎巴嫩和瑞典各国研 究的老年人和基层医疗护理工作人员，以及各国的协调员(他们的名字请参见参考文献页)与许 多作为地方咨询顾问的专家。 另外，要感谢以下这些世界卫生组织的工作成员，他们协助完成了这次WHO/INPEA的 研究和报告： Isabella Aboderin博士，非传染性疾病预防与健康促进部门；Alexander Butchart博 士，伤害与暴力预防部门；Magdalena Cerdá女士，伤害与暴力预防部门；Claudia Garcia Moreno博士，性别与女性健康部门；Etienne Krug博士，伤害与暴力预防部门；Martha Pelaez博士，老龄化地方顾问，WHO/PAHO。 还要特别感谢国际帮助老人组织(HAI)为管理该项研究所提供的持续帮助，尤其是HAI政 策官员Fiona Clark女士。 最后非常感谢日本政府所提供的经费支持。 文章的副本可以从以下渠道获得： 老龄化与生命过程小组 非传染性疾病预防与健康促进部门 非传染性疾病与精神健康部门 NMH/NPH/ALC 世界卫生组织 20 Avenue Appia 1121 Geneva 27 Switzerland 传真：+41(22)7914839 电子邮箱：activeageing@who.int

建议引用方式：WHO/INPEA. Missing Voices: views of older persons on elder abuse. Geneva, World Health Organization, 2002.

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Acknowledgements The project was initiated by Dr Alexandre Kalache, Coordinator of the World Health Organization Ageing and Life Course unit (WHO/ALC), who invited the International Network for the Prevention of Elder Abuse (INPEA) to join WHO in developing a global response to elder abuse. Professor Gerry Bennett, from Barts and the London Queen Mary’s School of Medicine and Dentistry in the United Kingdom and Secretary of INPEA, became the main researcher of this study. Ms Silvia Perel Levin, WHO/ALC Technical Officer, was appointed the focal person for the project, designed the focus groups protocol and coordinated the project under the supervision of Dr Kalache and Professor Bennett. Ms Silvia Straka, from McGill University in Canada, performed the qualitative analysis of the study. Professor Gerry Bennett, Ms Silvia Perel Levin and Ms Silvia Straka wrote this report.

Special thanks are due to the older persons and primary health care workers who participated in the national studies in Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden, as well as to the national coordinators (please see all their names in the references page) and the many experts who acted as local advisors.

In addition, thanks are due to the following WHO staff members, who assisted in the development of the WHO/INPEA study and the finalization of the report: Dr Isabella Aboderin, Department of Noncommunicable Disease Prevention and Health Promotion; Dr Alexander Butchart, Department of Injuries and Violence Prevention; Ms Magdalena Cerdá, Department of Injuries and Violence Prevention; Dr Claudia Garcia Moreno, Gender and Women’s Health; Dr Etienne Krug, Department of Injuries and Violence Prevention; Dr Martha Pelaez, Regional Advisor on Ageing, WHO/PAHO. Special thanks are given to HelpAge International (HAI) for their continuing support towards the conduction of this study, in particular to Ms Fiona Clark, HAI policy officer.

The financial support of the Government of Japan is gratefully acknowledged.

Copies can be obtained from: Ageing and Life Course Noncommunicable Disease Prevention and Health Promotion Noncommunicable Diseases and Mental Health NMH/NPH/ALC World Health Organization 20 Avenue Appia 1121 Geneva 27 Switzerland Fax: +41 (22) 7914839 e-mail: activeageing@who.int Suggested Citation:WHO/INPEA. Missing voices: views of older persons on elder abuse. Geneva, World Health Organization, 2002.

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执行总结 老年人虐待，即对老年人的错误对待，尽管这种人际间的暴力现象已经经历了漫长的时 间，现在终于得到了应有的关注。迄今为止，关于老年人虐待的流行病学研究还只限制于发达 国家。在发展中国家，虽然没有流行病学研究或者系统的统计数据收集，但是犯罪记录、新闻 报道、社会福利记录和小规模调查还是提供了证据，显示对老年人的虐待、忽视以及财产剥削 是非常普遍。 世界卫生组织(WHO)深感有必要为预防老年人虐待发展一套全球策略。目前在世界卫生 组织非传染性疾病与健康促进部门、老龄化与生命过程小组、世界卫生组织伤害与暴力预防部 门、国际老年人虐待预防网络(INPEA)、国际帮助老人组织以及一些国家的学术机构合作伙伴 的共同协作下，这个策略正在被逐步发展。 这项策略首先的第一步是在以下八个国家建立的一项研究：阿根廷、奥地利、巴西、加拿 大、印度、肯尼亚、黎巴嫩和瑞典。这项研究的主要方法是管理指导由社区老年人和基层医疗 护理工作人员组成的专题小组，目的是确定老年人自身以及那些构成基层医疗护理队伍的人员 所认同的老年虐待的内涵。之所以选择把焦点放在基层医疗护理环境，是因为在这些环境下老 年人虐待问题最容易被发现——同时也容易被忽视。因此让基层医疗护理工作人员了解老年人 虐待问题是预防与/或管理老年人虐待的关键性步骤。 这份报告展示了这次研究的设计和研究发现，以及一个会议(日内瓦，2001年十月11-13 日)的结论，该会议的目的是确认这些研究发现对政策、下一步研究和行动的启示。在这个会 议上，审阅和分析了各个国家研究小组准备的报告。 对于主要题目的分析显示出它们在各个国家之间具有的显著相似性。老年人对虐待的观点 主要分为三个大的领域：

・ 忽视——隔离，遗弃与社会排斥 ・ 侵害——对于人权、法律权利与医疗权利 ・ 剥夺——对于选择权、决定权、身份、财产与尊严 会议的结论包含了对行动的建议，其中一些已经实施，而另一些将在不久的将来继续开 展。这些建议可以总结为如下几方面：

・ 开发一套老年人虐待筛查与评估工具，在基层护理系统使用 ・ 开发一套关于老年人虐待的教育计划，用于培训基层护理专业人员 ・ 开发并传播一个研究方法工具包，用于研究老年人虐待 ・ 建立一个关于暴力与老年人的小型数据库 ・ 确保研究发现通过科学期刊顺利传播 ・ 建立全球资料库积累有效实践经验 ・ 通过提高大众对于老年人虐待问题的普遍危害性的了解动员整个公民社会 3

Executive summary Elder abuse, the mistreatment of older people, though a manifestation of the timeless phenomenon of inter-personal violence, is now achieving due recognition. Prevalence studies concerning abuse of older persons have so far been restricted to developed nations. In devel- oping countries, though, there is no systematic collection of statistics or prevalence studies, crime records, journalistic reports, social welfare records and small scale studies to provide evidence that abuse, neglect and financial exploitation of elders are widely prevalent.

The World Health Organization (WHO) has recognised the need to develop a global strategy for the prevention of the abuse of older people. This strategy is being developed within the framework of a working partnership between the WHO Ageing and Life Course unit of the Department of Noncommunicable Disease Prevention and Health Promotion, the WHO Department of Injuries and Violence Prevention, the International Network for the Prevention of Elder Abuse (INPEA), HelpAge International and partners from academic institutions in a range of countries.

The initial step towards developing the global strategy was the set up of a study in eight countries: Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden. The study’s main approach involved the conduct of focus groups with older persons in the community, and with primary health care workers, in order to establish components of elder abuse as identified by older people themselves and by those forming the primary health care teams. A focus on primary health care context was chosen as it is within this context that elder abuse can first be identified — or overlooked altogether. Making primary health care workers aware of the problem is thus a crucial step in preventing and/or managing elder abuse.

This report presents the design and findings of the study, and the conclusions of a meeting (Geneva 11–13 October 2001) aimed at identifying the indications for policy, research and action emerging from these study findings. Reports from each country prepared by the national teams were reviewed and analysed at the meeting.

Analysis of the major themes revealed remarkable similarities across the participating countries.

Older people perceived abuse under three broad areas: • • •

Neglect — isolation, abandonment and social exclusion Violation — of human, legal and medical rights Deprivation — of choices, decisions, status, finances and respect

The conclusions contain recommendations for action, some of which are already being implemented, with others to follow in the near future. These recommendations can be summarised as follows: • • • • • • •

To develop a screening and assessment tool for use in primary health care settings To develop an education package on elder abuse for primary health care professionals To develop and disseminate a research methodology ‘kit’ to study elder abuse To develop a Minimum Data Set concerning violence and older people To ensure dissemination of the research findings through scientific journals To develop a global inventory of good practice To mobilize civil society through raising awareness of the widespread magnitude of elder abuse 4

介绍 从老年人的角度对老年人虐待所作的跨文化的探索研究很少，而其中大多数是以目前已有 的对虐待的含义的界定分类为前提的。 世界卫生组织(WHO)，国际老年人虐待预防网络(INPEA)决定启动一项研究来挑战已有的 定义。这项研究的第一步是去询问老年人和基层护理工作人员一系列的问题，来理解他们的观 点、他们自己如何归类老年人虐待以及他们的感受，以此为基础制定全球化的策略来对抗老年 人虐待问题。 尽管有方法上的限制，这项研究首次提供了多国的关于老年人虐待的资料。虽然资料有 限，但它提供了一个行动的纲领并为未来产生更多的研究项目提供了丰富的可能性。尽管这些 个人与集体的回答无法在国家或全球范围内具有普适性，并且同所有同类项目一样涌现出了许 多新问题，但这些发现确实为如何理解和解决老年人虐待进一步提供了事实基础。最终我们要 面临的挑战将不再仅仅是聆听那些声音，而是去相信并付诸行动。

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Introduction There are few studies that explore elder abuse from the perspective of older adults cross-culturally, and most of these begin with existing classifications of the meaning of abuse.

The World Health Organization (WHO), the International Network for the Prevention of Elder Abuse (INPEA) and partners decided to set up a study which challenges existing definitions. This study begins by asking older persons and primary health care workers themselves a series of questions in order to understand what their perceptions are, how they themselves classify elder abuse and what they perceive as the first steps needed for a global strategy against the abuse of older people.

Despite methodological constraints, this study provides the first multi-country set of information about elder abuse. While the data is limited it provides a richness from which to generate many future research projects as well as a platform for action. The individual and collective responses cannot be generalised either nationally or globally and, as with all such projects, many new questions have emerged. However, the findings do throw new light on how to perceive and approach elder abuse.

Ultimately the challenge for us all is not only to listen to what has been said, but to believe and act upon it.

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1. 背景 1.1 老年人虐待的研究历史 二十世纪后期，经历了漫长时间的人际间的暴力现象开始按年龄划分。在文学作品中显而 易见，但却被社会掩盖着的儿童与妻子虐待现象最先开始浮现。最初它们分别被称为“打小 孩”和“殴打妻子”，并且都被归在家庭暴力问题的范围内。最终，老年人虐待的问题(开始 被称作“打老人”)浮出水面。对于老年人的虐待现象的描述最早在1975年见于英国科学期刊 (Baker 1975,Burston 1977)。在美国，这些报告立即得到了社会政治关注，并迅速地开展 了立法行动。而在英国，这些问题15年之后才得到了政治信任和进一步研究(Ogg & Bennett 1992)。至此之后，对老年人的虐待受到越来越多的世界范围内的关注，紧跟对于人权、性别 平等、尤其是老龄化问题的关注。 老年人，在这里的上下文中指的是60岁及以上年龄的人。有预测指出到2025年全球老年 人口将翻倍，达到12亿。如今每个月约有100万人年龄到达60岁，并且其中的80%来自发展 中国家。尽管在发达国家中老年人所占人口比例更高，但在发展中国家中，老年人口数量的增 幅要更大。从1990年到2020年，老年人口增长率在德国、法国和瑞典预计将达到 30%-60%；与此同时，在发展中国家如泰国、肯尼亚和哥伦比亚，这一增长率预计将超过 300%，在印度尼西亚更将达到400%。发展中国家的老年人口所占人口比例也将超过翻番， 在20年以后达到12%。到2020年，古巴、阿根廷、泰国和斯里兰卡这些国家的老年人口所占 人口比例将超过美国(联合国，1998)。 针对这一人口统计图景而产生的一系列具体问题亟需考虑，首先就是性别问题。实际上在 所有国家中，女性都占老年人口的多数。目前，全世界58%的老年女性生活在发展中国家，到 2025年这一比例会上升至75% 。艾滋病的大规模流行正在从数量上和质量上改变着老年人的 生活处境，尤其是在非洲。全世界只有30%的老年人被列入了养老金计划中。无论是在发达国 家还是发展中国家，结构性不平等导致了低收入、高失业率、低劣的医疗服务、性别歧视和教 育机会的稀缺。在过去数十年里，发展中国家的老年人罹患传染病的风险明显地下降了，相对 地非传染性疾病的发病率却持续上升。这解释了慢性并且常常是致残性的疾病在发展中国家的 日趋盛行现在已经达到了发达国家的水平。 医疗技术对那些可获得或者支付得起费用的老人而言，延长了其免受生活能力丧失的困扰 的时间。遍布全球的剧烈的社会与经济变化——例如城市化、家庭变化与女性的工作参与，以 及持续的(如果不是在恶化的)贫穷和不平等，为老年人虐待的孳生提供了沃土。上了年纪的人 们面临的挑战是多种多样的。仅仅对这些挑战的认知是不足以预防老年人虐待的，各个年龄群 体和社会部门的积极参与或将改变那些促成老年人虐待的环境。

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1. Background 1.1 The history of elder abuse The timeless phenomenon of inter-personal violence has, in the latter part of the twentieth century, been framed within age-specific compartments. Societally hidden, but manifest in literature, child and wife abuse were the first to emerge. Both types of abuse were framed as family violence issues and were originally called baby battering and wife beating respectively. Eventually, the problem of elder abuse (which was initially called “granny battering”) emerged. The abuse of older people was first described in British scientific journals in 1975 (Baker 1975, Burston 1977). In the US, these reports were immediately viewed as a socio-political concern, and quickly led to legislative action. In the UK, it took a further 15 years for the issue to receive research and political credence (Ogg and Bennett 1992). The growing world-wide focus on the abuse of older people since then has sought to parallel the focus upon human rights, gender equality and especially population ageing.

Elders in this context are persons 60 years and over. Predictions indicate that by 2025 the global population of this age group will double to 1.2 billion. One million people turn 60 every month and 80 % of these are in the developing world. Although the proportion of older people out of the total population is higher in developed nations, the percentage of increase of the elderly population is greater in the developing world. Aged populations in Germany, France or Sweden are expected to undergo 30 to 60% increases from 1990 to 2020, while developing countries such as Thailand, Kenya and Colombia are predicted to experience more than a 300% rise and a higher 400% rise in Indonesia. The proportion of older people in the developing countries will more than double, reaching 12 percent of their total population in twenty years from now. By 2020, countries such as Cuba, Argentina, Thailand and Sri Lanka will have a higher proportion of older people than the US(UN, 1998).

Specific issues within this demographic scenario need to be considered, starting with gender. Women are the majority of the older population in virtually all nations. Today, 58% of older women live in the developing world. By 2025 this will increase to 75%. The AIDS pandemic, particularly in Africa, is changing the situation of older persons both quantitatively and qualitatively. Only 30 percent of the world’s aged are covered by pension schemes. Structural inequalities in both the developed and developing world result in low incomes, high unemployment, poor health services, gender discrimination and a lack of educational opportunities. Over the last few decades in the developing world the risk of communicable diseases in old age has considerably decreased, in contrast with increasingly higher rates of non-communicable diseases. This explains the increased prevalence of longterm and often disabling diseases reaching now the levels of their counterparts in the developed world.

Medical technology promises an old age with increasing periods free of disability for those who have access to or can afford it. Radical social and economic changes throughout the world—such as urbanisation, changes in family and participation of women in the paid work force, combined with persisting if not worsening poverty and inequality—provide a fertile ground for elder abuse. The challenges faced by ageing individuals are multiple. While recognition of these challenges will not prevent elder abuse, active involvement of all age groups and sectors in society could alter the conditions that allow it to develop.

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1.2 老年人虐待的定义 英国的老年人虐待应对措施(Action on Elder Abuse)提出的一项定义后来被国际老年人虐 待预防网络(INPEA)采纳。它是这么陈述的：“老年人虐待指的是在本应充满信任的关系中发生 的一次或多次致使老年人受到伤害或处境困难的行为，或以不采取适当行动的方式致使老年人受 到伤害或处境困难的行为。”(Action on Elder Abuse 1995) 迄今为止的研究和政策文献中， 老年人虐待有以下分类：

・ 身体虐待：导致疼痛或受伤的行为，强迫身体行为，身体/药物约束 ・ 心理/情感虐待：导致精神极度痛苦的行为 ・ 财产/物质虐待：对存款或生活资源的非法或不当地剥削/使用 ・ 性虐待：在老人非自愿的情况下与老人有任何性接触 ・ 忽视：有意/无意地拒绝或者无力承担赡养责任 这些定义还需要文化语境的支撑并且还有其他问题需要被纳入到整个框架内。举例来说， 在某些传统社会中老年寡妇会被遗弃并剥夺财产。在许多非洲和南亚地区，寡妇在丧礼中会遭 遇残酷刑罚、性暴力、逼婚以及驱逐出家。在地方共同体当中，孤立的老年女性会被指控使用 巫术，往往只是因为一些无法解释的事件。这些暴力行为来自被牢牢嵌于社会结构的传统习俗 当中，同样需要被纳入老年人虐待的广泛考量。

1.3 老年人虐待问题的影响范围 目前被承认的老年人虐待的发生率的数据来源于五个发达国家中的社区调查。其中两个是 国家范围的，分别在加拿大和英国(Podnieks 1992, Ogg & Bennett 1992)。其他几个研究 分别调查了一个芬兰小镇的退休人口，以及波士顿和阿姆斯特丹的代表性样本。尽管研究方法 有所差异，所有类型的老年人虐待总的发生率都在4%到6%之间。 尽管研究机构中有大量关于护理质量问题的文献，但没有现成的老年人虐待发生率的数 据。一个关于美国某一个州的疗养院员工的调查显示，36%的护士和护理助手报告在去年一年 里至少有一次看到同事曾经对患者实施身体虐待，10%的人承认自己曾经对患者至少实施过一 次身体虐待。81%的人观察到至少一次对患者的心理虐待，同时40%的人承认实施过这类行 为。 尽管在发展中国家中还没有对老年人虐待的发生统计数据有过系统的收集，犯罪记录、新 闻报道、社会福利记录和小规模的研究都包含有证据显示，对于老年人的虐待、忽视和财产剥 削的普遍程度要大大超过社会的预期。

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1.2 Definitions of elder abuse The UK’s Action on Elder Abuse developed a definition subsequently adopted by the International Network for the Prevention of Elder Abuse. It states: “Elder abuse is a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (Action on Elder Abuse 1995). In the research and policy literature so far, elder abuse has been categorised as: • • • • •

physical abuse: the infliction of pain or injury, physical coercion, physical/chemical restraint psychological/emotional abuse: the infliction of mental anguish financial/material abuse: the illegal or improper exploitation and/or use of funds or resources sexual abuse: non-consensual contact of any kind with an older person neglect: intentional or unintentional refusal or failure to fulfil a care-taking obligation

Definitions require a cultural context and other issues need to be included within the total framework. For example, in some traditional societies older widows are subject to abandonment and “property grabbing”. Mourning rites of passage for widows in most of Africa and South Asia can include cruel practices, sexual violence, forced marriages and evacuation from their homes.

Accusations of witchcraft are directed at isolated older women, often connected with unexplained events in the local community. These acts of violence are customs that have been firmly imbedded in the social structure and need to be considered in the broad context of elder abuse.

1.3 The scope of the problem The accepted prevalence rates of abuse of older people are drawn from five community surveys carried out in developed countries. Two were national in scope, in Canada and the United Kingdom (Podnieks, 1992, Ogg & Bennett 1992). The other studies used the retired population of a small Finnish town and representative samples in Boston and Amsterdam. Although the methodologies varied the prevalence for all types of abuse ranged between four and six percent.

Despite the fact that a vast literature exists on quality of care issues in institutions, no prevalence or incidence data are available. A survey of nursing home personnel in one US state disclosed that 36% of the nursing and aide staff reported having seen at least one incident of physical abuse in the preceding year by other staff members and 10% admitted having committed at least one act of physical abuse themselves. At least one incident of psychological abuse against a resident was observed by 81% of the sample and 40% admitted to committing such an act (Pillemer 1990).

Although there is no systematic collection of statistics or prevalence studies in the developing world, crime records, journalistic reports, social welfare records and small scale studies contain evidence that abuse, neglect and financial exploitation of elders are much more common than societies admit.

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2. 项目 2.1 研究目标 基层护理工作人员常常会遇到各种老年人虐待的迹象，但是可能却并不知道如何识别以及 对待这些问题。联合国卫生组织和国际老年人虐待预防网络于2001年2月最新发起的全球应 对老年人虐待问题项目的总的目标，便是提高医疗专业人士和公众对于遍及全球的老年人虐待 问题的认识程度，并且在基层医疗服务的体系中发展出一套预防老年人虐待的全球战略。 2001年内，这个项目的第一阶段的具体目标有以下一些方面：

・ 建立一个顾问团队(WHO/INPEA)来发展和监督指导这个项目 ・ 在五个(有可能发展为发达国家的)发展中国家的城市地区开展初步探索性质的专题小组研 究，在涉及老年人虐待问题最紧密的人群——老年人自身和基层护理工作人员中，搜集他 们对老年人虐待问题的观念、信仰和态度并从中筛选出关键的主题和问题

・ 联系各国的协调员和促进员共同完成最初的定性分析 ・ 举办为期3天的促进会议讨论该研究对于政策制定和进一步研究的启示 ・ 计划在特定国家实行的更深入研究，更具体地探讨老年人虐待的本质、原因和影响 通过世界卫生组织和国际老年人虐待预防网络委员会委员以及国际帮助老人组织 (HelpAge International)的专门联系，五个发展中国家——阿根廷、巴西、印度、肯尼亚和 黎巴嫩参与了这次研究项目。之后来自三个国家——加拿大、奥地利和瑞典的代表愿意自费加 入这个研究项目并且支持同样的研究目标。 这项研究的一个关键特点是强调捕捉并报告老年人自身对于老年人虐待问题的观点和看 法，并以此为基础讨论公共医疗政策的作用。世界卫生组织希望站在一个独特的角度将这些讨 论转化为具体的行动要点来帮助全世界的基层护理工作人员预防老年人虐待。

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2. The Project 2.1 Aims and objectives Primary health care workers are often confronted with signs of elder abuse, but may not know how to recognise or act on them. The overall aim of the new WHO/INPEA Global Response Against Elder Abuse Project, started in February 2001, is thus to raise the awareness among health professionals and the public at large about the problem of elder abuse world-wide, and to develop a global strategy within the context of Primary Health Care for the prevention of elder abuse.

The specific objectives of the first stage of the project, in 2001, were to: • •

• • •

Establish an advisory group (WHO /INPEA) to develop and monitor the project Carry out focus group research in urban settings in five developing countries (with the potential expansion into developed countries) as an initial exploration to identify key themes and issues relating to the perceptions, beliefs and attitudes about elder abuse among the persons most concerned: older persons themselves and primary health care workers.

Involve national coordinators and facilitators to carry out initial qualitative analyses Hold a 3 day facilitated meeting to identify implications for policy action and research.

Plan further more in-depth research within particular countries contexts to explore in more detail the nature, causes and impact of elder abuse.

The five developing countries Argentina, Brazil, India, Kenya and Lebanon were engaged through professional links of WHO, INPEA board members and HelpAge International. At a later stage representatives from three countries, Canada, Austria and Sweden offered to join the project at their own expense and support the project aims and objectives.

A key feature of this project is an emphasis on capturing and reporting older peoples’ own views and perceptions of elder abuse and using these as a basis for discussions on the consequences for health and public health policy. WHO enjoys a unique position to convert this debate into concrete action points which will assist Primary Health Care workers globally to prevent elder abuse.

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2.2 研究方法 选择专题小组访谈法是因为它能够发掘被访者的知识和经验，它不只有助于考察人们怎么 想，同时还能考察他们如何思考以及为什么以这样的方式思考。这个方法的一个主要优点在于 专题小组的自然环境设定。参与者在表达小组成员普遍具有的感受时会获得互相间的鼓励，即 便他们认为这些想法偏离了主流文化(或者被研究者默认的文化)。在专题小组成员的讨论和对 话中往往会积极涌现出各种主题和观点。 顾问团队在每个国家指定了一位协调员来监督研究项目的执行。每一位协调员指定一位促 进员，根据关于专题小组招募和管理方法的具体指导方针，组织并运作专题小组访谈。 在每个国家中各有八个专题小组，每个小组由八到十人组成。其中六个小组由老年人组 成，另外两个由基层护理工作人员组成。老年人小组中有两个小组仅由老年女性组成，另有两 个小组仅有老年男性组成。剩下的小组，包括基层护理工作人员的小组中，性别是混合的。专 题小组的成员尽可能广泛地代表各种社会和专业背景，通常已有的社会团体和俱乐部更容易吸 引人们参与到讨论中来。参与者不必曾经遭遇过或者具有老年人虐待方面的知识。具体的专题 小组成员的招募方法在各国的研究报告中有详细描述。 参与人员可以享受到茶点或者一餐，并且可以报销他们的差旅费和其他相关费用。除此之 外没有提供其他形式的报酬。 专题小组的讨论目标并不是试图去获得那些可能曾经遭遇过虐待的人们的证言。事实上， 讨论是用来探索老人们和基层护理工作人员对老年人虐待问题的态度和信念。专题小组的讨论 目标是获得人们对以下一些问题的普遍看法的更深理解：

・ 老年女性和男性面临的主要问题 ・ 老年人在他们社区中的角色 ・ 老年人虐待是什么以及有哪些不同类型 ・ 老年人虐待发生的环境以及察觉得到的起因 ・ 老年人虐待对老人本身、他们的家庭以及社区造成的后果 ・ 老年人虐待现象在这一地区是否普遍及其原因 ・ 老年人虐待是否具有周期性因素或模式，比如说虐待是否会和每个月养老金发放的时间相 关，或者围绕着对社区有特殊重要性的节日例如宗教节日等等

・ 老年人虐待作为一个健康问题以及基层护理工作人员对此的关注点 ・ 关于暴力和虐待的已有的/需要的健康和社会服务以及社区支持 ・ 以后应对虐待、关注和预防所面临的差距、需求和视角

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2.2 Research methodology Focus groups were selected for their ability to explore people’s knowledge and experiences and to examine not only what people think but also how they think and why they think that way. A major advantage of this method is the natural setting of the focus group. Participants can also provide mutual support in expressing feelings that are common to their group but which they consider to deviate from mainstream culture (or the assumed culture of the researcher). Themes and perceptions often emerge particularly well in the discussion and dialogue between participants of focus groups.

The advisory group identified in each country a coordinator to oversee the research project. The national coordinator appointed a facilitator to organise and run the focus groups according to detailed guidelines concerning the recruitment methodology and the management of the groups.

Eight focus groups, each with eight to ten people, were held in each country. Six groups comprised older people and two involved primary health care workers. Two groups of older people were held with older women only and two with older men only. The remainders, as well as the groups with primary health care workers were mixed. Groups represented as wide a range of social and professional backgrounds as possible and often existing social groups or clubs facilitated the process of engaging men and women to participate in the discussions. Participants were not expected to have been exposed to or had previous knowledge of elder abuse. The recruitment methodology for the focus group is described in detail the countries’ research reports.

Participants were provided with refreshments, or a meal, and reimbursement for their travel and related expenses. Other forms of remuneration were not provided.

The focus groups did not aim to seek to obtain testimonies from those who might have experienced abuse. Instead, the discussions were used to explore older people’s and health care professionals’ attitudes and beliefs concerning elder abuse. The aim of the focus group discussions was to obtain a better understanding of common perceptions about the following: • • • • • • •

• • •

Main problems faced by older women and men Older people’s role within their communities Perceptions of what elder abuse is and what are the different kinds Perceptions of the contexts in which abuse occurs, and its perceived causes The consequences of elder abuse for older people, their families and the community Whether elder abuse is common in the area and why Whether there are “seasonal” influences or patterns on abuse, for instance would abuse be related to the period of the month when a pension is cashed or around festivities that can trigger special stress in the community such as religious holidays, festivals etc Perceptions of elder abuse as a health issue and as an issue of concern for health care workers.

Identification of existing/needed health and social services and community support in relation to violence and abuse Definition of gaps, needs and views for future responses to abuse, care and prevention

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2.3 定性资料分析：国家报告 每个国家的协调员完成了一份报告，详细地描述了他们的专题小组讨论中涌现出来的各种 主题，并且用逐字的引用加以阐明。所有的非英语报告都被翻译成了英语。(各国的报告可以 申请索要并且可以在该网页中找到：http://www.who.int/hpr/ageing/elderabuse) 项目小组的一位成员审阅了翻译好的各国的国家报告并完成了内容分析。由于报告的多样 性，内容分析的主要目的是识别出那些与研究的中心问题相关的重复出现的主题。国家报告中 的评注按照主题分类进行了编码，便于有系统地阅读。顾问团队的首席调查员完成了一次对报 告的独立阅读以进一步识别主要的主题。尽管在选择的方法和资源上有一定的限制，最终的分 析还是揭示出了这次研究收集到的信息的独一无二的丰富性。 分析的中心议题是开始理解老人们和医疗专业人士对老年人在社会中的角色以及面临的问 题是如何思考的，以及他们如何思考老年人虐待问题及其可能的解决方案。这些主题出现在了 所有的报告中，尽管因各个地区的环境差异而表现形式有所不同。这些主题引起了特殊的关 注，在于它们反映了关于老年人虐待和老年人经历具有全球共性的方面。其他的主题则更具体 到一个或一些国家，也反映了老年人虐待具有环境的特异性。

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2.3 Qualitative data analysis: national reports Each national coordinator developed and wrote a report detailing the themes emerging in their group discussions and illustrating with verbatim quotes. All non-English reports were translated into English. ( country reports are available upon request and can be viewed at http://www.who.int/hpr/ ageing/elderabuse) A member of the project team reviewed the translated national reports and performed a content analysis. Because of the variability in the reports, the main goal of the content analysis was to identify recurrent themes linked to the central questions of the study. The remarks in the national reports were coded into thematic categories, following a systematic reading. The chief investigator of the advisory team performed an independent reading of the reports in order to further identify major themes. In spite of some limitations in the chosen methodology as well as resource constraints, the final analysis revealed the unique richness of the information gathered by the study.

The central concern of the analysis was to begin to understand how older adults and health care professionals understand the roles of older adults in their societies as well as the problems they face, and how they understand the problem of elder abuse and its possible solutions. Certain themes emerged in all the reports, although often taking different shape, depending on the local context.

These themes were of particular interest, as they reflected aspects of elder abuse and experiences of older adults that could reveal universal treads. Other themes were more specific to one or a few countries, also of interest in reflecting the contextual specificity of elder abuse.3

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3. 发现和讨论 从专题小组中涌现出来的资料对老人们和基层护理工作人员如何理解老年人虐待这个复杂 问题提供了独特的洞见。 从参与者对他们观点和经验的阐述中浮现出一些老年人虐待的关键的类型。虽然其中一部 分类型和文献中的内容吻合，但其余的类型迄今为止还没有在通常的关于虐待的分类中出现 过。进一步地，参与者所着重强调的一些类型的虐待和以往由医疗专业人士在文献中认为最重 要的类型经常有所区别。 关于老年人虐待的文献到目前为止都把焦点放在个人和家庭因素上。研究通常都聚焦在施 虐者和受害者的特征，以及家庭成员间的人际矛盾上面。它们关注病理学因素，财产虐待、精 神疾病和认知障碍在老年人虐待中扮演了主要角色。这样分析的一个后果就是老年人虐待始终 还是被视作家庭问题，而不是被看做一种更大的社会问题。目前这项研究通过记录至关重要的 社会结构性因素，挑战了这样一种聚焦个人层面的视角，事实上支持了发展中国家报告的老年 人虐待的种种方面。 以下就是参与者所识别出来的老年人虐待的关键类型：

・ 社会结构性虐待 ・ 忽视与遗弃 ・ 对老年人的不尊敬与歧视 ・ 心理上的、情感上的、言辞上的虐待 ・ 身体虐待 ・ 法律与财产虐待 这次研究也证实了将老年人虐待作为一个话题来讨论对一部分老人来说是多么困难——数 份报告中提到他们表现出对问题的不适/拒绝回应。例如，尽管配偶和性虐待问题被提上讨论 议程，但是大多数专题小组都不认为它值得主要关注。类似地，身体虐待问题也很难被参与者 们讨论，除非他们将问题置换或者说把它放在他们自身或者他们的社区以外的背景下。这种形 式的虐待往往被认为是一种独立的类型，区别于其他形式的错误对待。即使有人承认这样的虐 待可能或者确实发生在他们所处的社区(或许甚至就发生在参与者自己身上)，事实上也很少有 人直接提及身体虐待，而只是从叙述里面显出端倪。然而，这样的虐待似乎总是潜藏在一个个 故事的背后。 这种现象在印度的报告当中尤其显著。印度的专题小组的促进员在讨论开始时小心地避免 使用“虐待”这个术语。当之后被问到关于虐待的问题时，参与者们都将虐待与极端暴力的行 为事件联系起来。讨论身体虐待事例的时候大家普遍显示不安并且真心希望回避这些讨论。所 有专题小组都否认在他们的社区中存在身体暴力。这产生了一个为“虐待”下定义的问题，因 为据他们的叙述，“虐待”在印度不存在。他们会这样说 17

3. Findings and discussion The data emerging from the focus groups has provided a unique insight into how the complex subject of elder abuse is perceived by older persons and primary health care teams.

Several key categories of elder abuse emerged in respondents’ accounts of their perceptions and experiences. While some of these categories were the same as those found in the literature, others have not so far been recognised in the usual taxonomy of abuse. Furthermore, the emphasis that participants placed on certain types of abuse often does not match those concerns identified in the literature by health care professionals as being the most important.

The elder abuse literature so far places the focus on individual and familial factors. Research often focuses on the characteristics of the perpetrator and the victim, and on the interpersonal dynamics within the family unit. There is an emphasis on pathology, with substance abuse, mental illness, and cognitive disabilities playing a major role in elder abuse. The effect of such an analysis is that elder abuse remains a family problem, rather than being viewed as a larger societal concern. This study challenges such an individualistic focus by documenting the vital importance of structural-societal factors, underpinning virtually all aspects of elder abuse reported from developing countries.

The following are the key categories of abuse identified by participants: • • • • • •

Structural and societal abuse Neglect and abandonment Disrespect and ageist attitudes Psychological, emotional and verbal abuse Physical abuse Legal and financial abuse

The study has also established how difficult elder abuse is as a topic for some older adults to discuss — a fact mentioned in several of the reports being discomfort/denial of the problem. Spouse and sexual abuse, for example, though discussed, were not regarded as being of major concern to the majority of focus groups. Similarly physical abuse was very difficult for participants to discuss, unless they displaced it or otherwise put it outside of themselves or their communities. This form of abuse was often considered as a separate category from the other forms of mistreatment. While there was admission that it could and did happen in their community (perhaps even to the participants themselves), there was actually very little direct mention of physical abuse, although it sometimes surfaced in stories. However, it seemed like it was always lurking on the margins of the narratives.

This phenomenon was particularly pronounced in the India report. The focus group facilitators in India were careful not to mention the term “abuse” at the beginning of the focus groups. When asked about abuse, later, participants linked abuse to extreme cases of very violent behaviour. There was a general uneasiness about discussing cases of physical abuse and a genuine attempt was made to avoid the issue. The groups all denied the existence of physical violence in their communities. This created an issue in getting definitions of “abuse,” because for them, “abuse” does not exist in India.

What they would talk about was

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“情感问题”，“缺少情感上的支持”，“被家庭成员忽视”，“感到不安全”，“缺乏 尊严”，“恶意对待”，“不被家人尊敬”。然而，没有任何一个人愿意冠以“虐待”的 称谓。(印度) 心理的、情感的和言辞的虐待被频繁地讨论。因为这些虐待的施虐者同时存在于家庭中和 社会中，它们被放在社会结构性虐待这一类。对老年人的不尊敬与歧视以及具体环境下的虐待 放在之后描述。 在“虐待(abuse)”(没有发生在他们所处的社区中)和“错误对待(mistreatment)”(他们 承认确实发生)两个概念之间有着明显的区分。 除了以上主要的虐待类型，参与者们在叙述中强调了一些具体的环境，在其中老年人虐待 部分地是因为社会的制度性安排所致。它们包括：

・ 退休老人的社会角色 ・ 长期护理机构 ・ 医疗护理专业人员作为施虐者或者受害者 ・ 具体文化差异对虐待的影响 最后，有两个关键因素表现出对所有形式和环境下的虐待有影响作用：性别和社会经济地 位。尽管参与者描述了在各自国家这两个因素影响老年人虐待的不同方式，两个关键点还是浮 现了出来。第一，有一种盛行的观点认为女性，尤其是(贫穷的)无子女的或者寡妇，最容易受 到虐待。第二，更普遍的情况是，尽管老年人虐待涉及所有社会阶层，参与者们一致认为贫穷 的的老年人群体遭遇最严重。 以下的部分使用对国家报告和逐字记录稿的摘录，将详细地讨论专题小组的参与者识别出 的老年人虐待的主要类型和具体环境。打引号的部分表示这是参与者在专题小组中的陈述，用 线框起来的部分表示这是各国协调员在其报告中的陈述。

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“emotional problems,” “lack of emotional support,” “neglect by the family members,” “feeling of insecurity,” “loss of dignity,” “maltreatment,” “disrespect by the family.” However, not a single person was willing to label it as “abuse.” (India) Psychological, emotional and verbal abuse were frequently discussed. As perpetrators of these kinds of abuse were said to be found in families and in society, they are present in the report within the categories of structural and societal abuse; disrespect and ageist attitudes and within concrete contexts described below.

There was a clear dichotomy between the concepts of “abuse” (which does not happen in their communities) and “mistreatment” (which they admit does happen).

In addition to the main categories of abuse, the respondents’ accounts highlighted several con- crete contexts in which elder abuse occurs as part of social or institutional arrangements. These included: • • • •

Retirement and social roles of older adults Long term care institutions Health care professionals as abusers and as victims Culture- specific influences on abuse

Finally, two key factors emerged as underpinning virtually all forms or contexts of abuse: Gender and Socio-Economic Status. Whilst participants described different ways in which these factors affect elder abuse in their respective countries, two crucial points emerged. First, there was a prevailing view that women, particularly the (poor) childless and widow, are the most affected. Second, and more generally, although elder abuse affects all social classes, respondents agreed that it is the poor older people who suffer the most.

Using extracts from the national reports as well as verbatim quotes, the following sections discuss in detail the main categories and concrete contexts of elder abuse identified by the focus group participants. Quotation marks indicate a participant statement within a focus group and the boxed areas indicate statements made by the national coordinators in their reports:

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3.1 虐待的主要类型 A) 社会结构性虐待 参与者，尤其是来自于发展中国家的参与者，将他们在家中、在公共场合、在医疗护理机 构所经历的错误对待主要归咎于政府和社会结构因素。即使在一些发达国家，如瑞典的专题小 组讨论中，对于老年人虐待的预防和干预的责任也被归于政府的层面。对于老年人虐待的预防 显然被视作一种公共职责，政府的一部分责任就是关心在其社会中处于弱势的人群。参与者们 频繁地提到下面这些问题作为政府未能履行对老年人职责的具体例子：削减预算、公共支出的 错误优先权、医疗护理人员的削减和对医疗护理机构监管不力。 尽管不同报告使用的表述不尽相同，所有发展中国家的参与者都提到了阿根廷报告中所称 谓的社会虐待。许多国家的参与者都认为这是最重要的一类虐待并且是他们所经历的个人层面 的其他大多数类型的虐待的根源。社会虐待涵盖了范围很广的问题，比如收入保障和住房问 题。 阿根廷参与者将社会虐待定义为年龄歧视，尤其表现在养老金的不足。在阿根廷，原本就 被认为过低的养老金最近下调，以至于许多人连最低需求和曾经拥有的最低享受也难以维系。 关于住房，各国的参与者都提到这样一个问题，即能否确保仍住在自己家住房的权力不被 侵犯。

许多情况下子女接管了对他们父母房产的管理，渐渐地但几乎必然地老人们丧失了对于他 们居住空间的控制甚至有时候不得不在很糟糕的情况下离开原来的房屋，例如搬到一个更 小的居住环境、和另一个亲戚如兄弟姐妹同住、甚至被迫进养老院居住。(巴西) 印度的报告通过一位退休鳏夫的境况例证了这一问题，他有自己独立的房产，但是现在不 得不和他的独生子和儿媳以及他们的两个孩子一起居住。

他在用餐、作息时间、家务等方面丧失了自由选择的权利。如果他对此提出一些意见，家 人总是让他管好自己的事就行了。尽管他试图让他儿子及其家人离开自己的房子，他们都 拒绝了。事实上，他甚至提出自己想寻找伴侣而去再婚，那么他们必须离开这房子供他独 立使用。他们依然对他的意见无动于衷而没有搬走。成年子女和父母同住这样的问题对于 低收入家庭来说更为严重，因为往往他们的住房面积更小。(印度)

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3.1 Key categories of abuse A) Structural and societal abuse Participants, particularly from developing countries, primarily blamed governments and structural factors for the mistreatment they experience in their homes, in public, and in health care institutions.

Even in some focus groups in developed countries, such as Sweden, the responsibility for elder abuse prevention and intervention was placed at government level. The prevention of elder abuse is clearly viewed as a public responsibility, and part of governments responsibilities is to care for vulnerable people in their respective societies. Participants frequently mentioned issues such as budget cuts, wrong priorities in public spending, cutbacks in health care, and insufficient supervision of health care institutions as concrete instances of governments’ failure to fulfil their responsibilities towards older people.

Although different expressions were used in the various reports, participants from all the developing countries referred to what the Argentinian report called societal abuse. Many of the countries saw this as the most important type of abuse and as the root cause of most of the other types of abuse they experience at a more personal level. Societal abuse covers a very wide range of issues such as income security and accommodation.

The Argentinian participants defined societal abuse as age discrimination manifested particularly in inadequate pensions. Pensions, which were already considered low, have been recently lowered in Argentina to the point that many people find it difficult to cover the basic necessities and minimal luxuries they were able to previously afford.

The issue related to accommodation, feeling secure in the ability of living in their own home was referred to by participants from different countries.

On many occasions children take over their parents household management and slowly but steadily the elders lose their place within their own territory and even sometimes have to leave the premises in pretty bad conditions such as going to live in a smaller place, sharing with another relative like a sister or brother, or even get admitted to an old people’s home.

(Brazil) The Indian report exemplified the problem through the situation of a retired widower who owns his own apartment but is presently sharing it with his only son, his daughter-in-law and their two children.

He has lost his freedom of choice around meals, bedtimes, housekeeping, etc. If he makes suggestions, he is told to mind his own business.Although he has asked his son and his family to leave, they have refused. In fact, he has even suggested that he would like to remarry for the sake of a companion so they must leave the apartment for his exclusive use. They do not move out of his apartment but continue to neglect him. The problem of adult children living with their parents in their accommodation is worse for lower income families, because lodgings are smaller. (India)

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数份报告描绘了国家的经济危机是如何导致了老年人虐待，并且参与者们明确地将此归咎 于政府。 除了关于住房共享的问题，所有国家的参与者们都提到了社会角色的变化如何地造就了这 样的环境以至于他们被虐待和忽视。他们声称，在以前女性是呆在家里主要负责照顾孩子、无 法完全自理的老人和管理家务的。现在所有成年人都不得不出去工作挣钱，没有余力再照顾家 里。这普遍导致了对老人们的情感忽视，往往还伴随着对他们健康的忽视。中间年龄层的人们 因为生活的重担压力很大，他们一天工作回家很少有耐心再照顾家里的老人。最终的结果往往 就是言辞上的虐待，有时甚至是身体虐待。然而，许多老年人，即使把这样的行为称作虐待， 也还体谅着他们的孩子。他们认为这是因为他们的孩子生活在繁重的压力之下，相对地，他们 把主要责任归咎于政府的社会和经济政策。一位老年参与者在评判一个财产虐待的案例时这样 说道：

“他一定是急需这笔钱”(加拿大) 各国的许多小组也都提到了要享受社会和医疗服务非常不易，从质量和数量上都缺乏针对 老年人的服务。在肯尼亚、黎巴嫩和印度，参与者们声称政府没有医药与医疗服务计划，或者 已有的计划并不普及。一些最极端形式的身体虐待和漠视就在这些国家被提及。 从这些报告里反映出，政府关于基础服务的政策不力以及财政支出的缺乏被认为给家庭施 加了压力，引发了老年人虐待。这种压力表现为直接的经济压力，比如无法支付家中老人的医 疗服务费用，以及全面的压力与一种老人成为家庭负担的感受。医疗服务系统的问题常常和社 会经济地位与支付能力相联系。社会上最贫穷的那部分人与许多老年人(尤其是老年女性)处在 这类虐待问题之中。

有一个普遍的共识就是女性是最严重的受害者，她们没有自己的收入而完全依赖于配偶。 她们也倾向于对自己的健康问题轻描淡写仅仅缘于这样会对其他家庭成员造成困扰，因为 他们需要送她去看医生并且/或者在诊疗和药品上花钱。参与者们进一步认为若一位女性是 寡妇，她的处境将更糟，因为她的财产将只来源于她的子女因而完全由她的子女“决定她 是否需要医疗救助”，无论她怎么说。(印度)

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Several of the reports traced how economic crises in their countries resulted in elder abuse and participants clearly blamed governments for this.

Beyond the issue of how accommodation is physically shared, participants in all countries spoke about how changes in social roles have created situations where they end up abused or neglected.

They claim that formerly, women remained at home and were the primary caregivers for children and dependent older adults and looked after the household. Now that all adults in the family have to go out to paid jobs, there is no capacity left for caregiving. This results in widespread emotional neglect and often also physical neglect of older adults. Stress levels are high due to the pressures on the middle generation, who come home from their jobs and lack patience in dealing with their older family members. The result is often verbal abuse and sometimes even physical abuse. However, many older adults, even while naming such behaviour as abusive, excuse their children. They recognize that their children are living under a great deal of stress and instead place the pri- mary blame on government social and economic policies. An older participant justified a case of financial abuse by saying

“ He must have needed the money” (Canada) Many groups across the countries also spoke of difficulties related to access to health and social services as well as the lack of services for older people, both in terms of quality and quantity. In countries, such as Kenya, Lebanon and India, participants claimed that there is no government health care and medication plan, or that existing plans are not universal. Some of the most extreme and physical forms of abuse and neglect were referred to in these countries.

It emerges from these reports that inadequate government policies and lack of funding for basic services is viewed as placing pressure on families and older adults and thus leading to elder abuse.

The pressure takes the form of direct financial pressure, such as not being able to afford to provide medical care to older family members, as well as overall stress and a sense of the older person being a burden on the family. Issues around the health care system were often linked to socio-economic status and ability to pay. The poorest members of society are the worst off, and many older adults (especially older women), fall into this category.

There was a general consensus that women were the worst sufferers, with no income of their own and dependent on spouses for everything. They also tended to underplay their health problems for the sole reason of causing inconvenience to the other family members by way of escorting them to the doctor and/or spending money by way of consultation fee and medicines. They further voiced that if the women were widows, the situation was even worse, because the finances then came from children for their welfare and it was the sole discretion of children to “decide whether she needed medical assistance or not” even if she said she did.

(India)

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B) 忽视与遗弃 到了最极端的情况，对老人缺少照顾会发展成遗弃老人，而在医疗设施中，必要的免费护 理的匮乏可能会导致致命的结果出现。巴西和肯尼亚的报告中涉及了将老人遗弃在医疗设施比 如医院里的行为。家人把老人留在医院里然后就不再接他们回去了。因此医院无法将老人送回 社区当中。这样的行为对于老人的身体和情感都会造成巨大的创伤。 在肯尼亚，将老人遗弃在医院被认为是老年人虐待中最主要的问题，这和老人或者家庭必 须完全支付医疗费用有直接关联。这项研究中的医院工作人员估计有15%到30%的老年病人 最终被遗弃在了医院。这还不包括那些被遗弃在家里或者街道上，然后被陌生人送进医院、慈 善机构或急救中心的老人。这些贫穷的老年病人还不能立即接受治疗直到一个免除医疗费用的 行政程序完成，在这中间的时间病人可能病情严重恶化甚至死亡。一位总护士管理员估计在其 医院90%的的被遗弃老人患上了临床抑郁症。另一家医院的护士长注意到抑郁使得老年病人在 医疗过程中不合作，致使药物治疗效果不好以及使得病人拒绝同意一些必要的医疗程序。 在巴西和肯尼亚，遗弃都表现出周期性的模式。如一位参与者所描述，在巴西，它和长 假、狂欢节、学校假期和圣诞节具有联系：

“到了学校假期，一个有郊外地方可去的家庭第一件做的事就是把家里的老人放到医院里 去”。(巴西) 在肯尼亚，周期性的遗弃和农业状况更紧密联系。肯尼亚的大部分经济属于农业和畜牧 业，因此地方经济非常依赖于气候状况。因此遗弃老年人在干旱季节、作物歉收时期和牲畜损 失时期更为多发。

C) 对老年人的不尊敬与歧视 参与者们所报告的不受尊敬的经历按照老人们的观点有必要被理解成其他所有形式的虐待 的原因，并且其本身也是一种重要的虐待形式。各个国家的老人们一致认为不受尊敬是最令人 痛苦的一种错误对待的形式。尽管报告中包含了一些令人印象深刻的身体虐待和忽视的故事， 很明显对于老人的不尊敬的态度是更普遍的。黎巴嫩的报告里有一句尖锐的引用，似乎表达了 这项研究中所有老人的心声：

“对一个老人来说，一次粗鲁的言语相比比拿刀刺他伤得还要深”。(黎巴嫩)

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B) Neglect and abandonment At its most extreme, lack of care for older adults results in abandonment and in health care set- tings fatal outcomes can occur due to deprivation of essential non-funded care. Both Brazil and Kenya reported the practice of abandoning older family members in health care facilities such as hospitals.

Families leave older members there and do not return to pick them up. Thus hospitals have no place to discharge older adults into the community. This has both severe physical and emotional impact on the older person.

In Kenya, abandonment of older adults at hospitals was considered the most significant issue in elder abuse, directly connected to the fact that the older person or the family has to pay directly for health care services. The hospital staff included in the study estimated that between 15 to 30 percent of older patients end up abandoned in the hospitals. This does not include older people who had already been abandoned in their homes or in the streets and brought by a stranger to the hospital, charitable institutions or emergency services. Such indigent older patients are refused medical care until an administrative process to provide a fee waiver is completed and in the interim, patients may seriously deteriorate or even die. In one hospital, the Chief Nursing Officer estimated that 90% of abandoned older people go into clinical depression. Another hospital matron noted that depression makes older patients uncooperative in the treatment process, rendering medication ineffective and leading to refusal to consent to necessary procedures.

In both Kenya and Brazil the patterns of abandonment were presented as seasonal. In Brazil, it was linked with long weekends, Carnival, school holidays and Christmas as described by a respondent:

“Over school holidays, the first thing a family who has a place to go in the countryside does, is to grab the elder and put him/her in a hospital”. (Brazil) In Kenya, seasonal abandonment was more linked with agricultural conditions. Most of the Kenyan economy is agricultural and pastoral, thus local economies are very dependent on climatic conditions.

Abandonment of older persons is thus higher in times of drought, poor crop yields or loss of livestock.

C) Disrespect and ageist attitudes The experiences of disrespect reported by participants need to be understood as viewed by older persons both as a cause of all other forms of abuse and as an important form of abuse in itself.

Disrespect is the most painful form of mistreatment identified by older adults in all countries. While the reports included some dramatic stories of physical abuse and neglect, it was clear that an attitude of disrespect towards older adults is universal. The report from Lebanon contained a poignant quote, which seemed to speak for the experiences of older adults throughout the study:

“One rude word said to an old man is stronger than stabbing him with a knife”.

(Lebanon)

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当公众和专业人士对老年人虐待的注意力集中在证据更确凿的身体健康影响上时，老年参 与者对虐待的观点和经历则主要集中在不尊敬这个主题上：

“人们带着轻视的口气对我们说话——叫我们‘小甜心’或者‘小宝贝’——告诉我们该 做什么”。(加拿大) “……闭上嘴，我们给什么你就拿什么，享受着就行了”。(加拿大) “尊敬比食物和饮料更宝贵”。(黎巴嫩) 一次又一次地，每次轮到发言参与者都说到人们的不尊敬。虽然我们将不尊敬与言辞和情 感虐待以及忽视联系起来，事实上它渗透在所有方面。不尊敬最终预示着社会对老年人态度的 恶化。许多小组认为年轻一代显得尤其的无礼。大家普遍认为社会流行的态度和价值观发生了 剧烈的改变，所以

“以前比现在好多了”。(瑞典) 推广对老年人的歧视和负面成见的责任被认为应归咎于媒体的影响，年轻人尤其容易被其 影响。一些人还认为西方化作为新兴的态度和价值观的载体也有责任。黎巴嫩小组所作的分析 特别的简洁并且也反映了在其他大多数报告中出现了的主题：

参与者们同时指责媒体忽略那些关于老年人的问题，促进了虐待性的行为。此外，被访者 们补充道，忽视老年人背后的原因是社会现代化过程中试图模仿西方文化。他们说以前那 些年代的人们更善解人意，关怀自己的父母和祖父母并且有礼貌。相反地，现在的年轻人 对长辈缺乏敬意并且漠不关心。参与者们认为如今家庭的纽带正在断裂，家庭的权威转移 到了孩子的身上，使得他们对于长辈不再那么尊敬。 肯尼亚和巴西的报告格外清晰地阐述了社会的态度如何在医疗护理系统内对老年人的不敬 中反映出来。

在医疗护理设施中，老人们从进门开始到接受照料的过程中一直在遭受着暴力。(巴西) 这位缺乏判断力的老人，可能因为受到治疗而表现兴奋，被当做任性的小孩一样对待。这 是很暴力的。一位医疗人员取出义肢，取出设备，摘掉老人的眼睛，这位老人开始不安。 当他不安的时候，这位医疗人员开始进行药物治疗……这是暴力。另外在一些其他的情况 下这位医疗人员曾说过：“如果你继续保持这个样子我就不让你女儿进来。”(巴西)

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While public and professional concern about elder abuse focuses on the more evident physical health impact, the theme of disrespect emerged as a major theme in older participants’ perceptions and experiences of elder abuse:

“People talk down to us- call us ‘sweetie’ or ‘dearie’- tell us what to do”. (Canada) “...just shut up, take what we give you, and just enjoy”. (Canada) “Respect is better than food and drink”. (Lebanon) Time and again, participants spoke of disrespect everywhere they turn. While disrespect is linked to verbal and emotional abuse as well as to neglect, it is more pervasive and all-encompassing.

Disrespect is ultimately an indicator of poor social attitude towards older people. Many groups considered the younger generations as being particularly disrespectful. There was a general agreement that social values and attitudes have dramatically changed, and that

“it was better in the old days” (Sweden).

Blame was given to the influence of the media in promoting ageist attitudes and negative stereotypes about older people, influences to which youth are particularly vulnerable.

Westernization was also blamed by some as the carrier of new attitudes and values. The analysis performed by the Lebanese team was particularly succinct and reflected themes that were found in most of the other reports: Participants also accused the media of neglecting issues concerning older people, and promoting abusive actions. Moreover, the interviewees added that the reason behind neglecting old people is the modernization of the society by trying to imitate the Western culture. They mentioned that in previous generations people were more sensitive, caring and polite towards their parents or grandparents. By contrast, today’s young people are disrespectful and careless towards older people. The participants believe that family bonds are collapsing, and that there is less respect for the elder, with the authority being shifted to the children. (Lebanon) The Kenyan and Brazilian reports were especially clear about how societal attitudes are also reflected in the disrespect within the health care system.

At the health care facilities, older persons suffer violence from the entrance door to care delivery. (Brazil) The disoriented elder, who may be intoxicated by medication is taken [and treated] as a headstrong child. This is quite violent; a professional to take out the prosthesis, take out the device, remove the eyeglasses [from the elderly], then he [the elderly]agitates. When he agitates [the professional] medicates ... this is violence; there are also cases in which he [the professional] says, “I won’t let your daughter in if you keep [behaving] like that.” (Brazil)

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在加拿大和阿根廷的报告中，对医疗护理系统中的虐待情境也有描述：

“他始终穿着尿布，从来没人带他去浴室”(加拿大) “老年人虐待就是你不得不等上两个月才能看一次免费医疗门诊，而你已经花了一辈子来 支付这费用”(阿根廷) 肯尼亚的报告与其他国家报告不同之处在于它专注于医疗护理系统的问题，将医疗护理系 统中对老人不敬的主题讨论得淋漓尽致。参与者们一直在描述老年人如何被看成一件麻烦事、 在医院不受欢迎并且被认为治疗他们是一种资源浪费。一位医院的院长对访谈员吐露的内容尤 其令人震惊：

“医院里的老人真是令人头痛，简直是浪费稀有的医疗资源。作为一个老年人组织如果你 们能把这些老年人请出我们医院，那真是帮了大忙了”(肯尼亚) 这种不敬渗透到肯尼亚所有层面的医疗护理系统，并且转化为各种严重的虐待、剥削和忽 视。 对老人的不敬也出现在各种政府和商业机构当中。为数不少的报告中提到，老人们要在银 行、政府办公室、警察局和医疗护理机构这些通常不舒服的环境下排队等过长的时间。不敬也 以其他形式在公共设施中表现出来。

“在邮局或者火车站，你被认为不应该说话说得太慢，并且如果你听力不佳常常会遭遇恶 劣的态度。”(奥地利) 在大多数报告中，公共运输系统作为另一个错误对待的来源而被提及。尤其是在巴西和奥 地利的报告中，而主要的潜在问题依然被认为是不尊敬：

不敬从老人到达公共汽车站的那一刻就开始了。当老人招呼公共汽车停下来的时候，司机 第一句说的话是：“这儿不停，车上已经塞满了65岁以上老人了。”老人在招呼着，而司 机已经开走了。有时候他们会停在前面，可怜的老人不得不跑步赶上公共汽车。这行为很 刻薄。(巴西)

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Abusive situations in the health care systems were also described in Canada and Argentina:

“He was kept in diapers and never taken to the bathroom” (Canada) “Elder abuse is to have to wait for two months for a free medical consultation which you have paid for in a way all your life” (Argentina) The Kenya report, which differed from the other country reports in its exclusive focus on the health care system, developed the theme of disrespect towards older people in the health care system very strongly. Participants consistently told of how older people are seen as difficult, are unwanted in hospitals and considered a waste of resources. Particularly shocking was the report of the head of one hospital, who confided to the interviewer:

“Older people are a big headache and a waste of scarce resources, the biggest favour you could do to me as an older people’s organisation is to get them out of my hospital.” (Kenya) This disrespect appeared to permeate the health care system in Kenya at all levels and translates into all kinds of serious forms of abuse, exploitation and neglect.

Disrespect is also encountered in various governmental and commercial institutions. A number of country reports referred to excessive waiting times by older adults, often in very uncomfortable circumstances, at banks, in government offices, at police stations and in the health care system.

Disrespect is also shown in other ways in public settings.

“At the post-office or at the railway station you are supposed not to speak too slowly and you are treated badly when you have a hearing problem.” (Austria) Public transport was mentioned in most of the reports as a further source of mistreatment. Most strongly in the Brazilian and Austrian reports, the main underlying problem is again identified as disrespect: Disrespect starts from the moment the elder gets to a bus stop. When he hails the bus to stop, the first thing the driver says [to himself] is, ‘don’t stop here, as it is full of six five [people 65 years or more].’ The elder hails, but them [drivers] keep going. Or they stop way ahead, so the poor old guy has to run to catch the bus. It is mean. (Brazil)

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“公共汽车司机在这位老妇人还有两步路就可以上车的时候关上了车门。然后，他再次把 门打开却非常生气对着她一顿责骂”(奥地利) “最近在公交巴士上，一些年轻人曾坐在我的旁边。当一些老人上车的时候，这些年轻人 非但不让座位给他们，反而还说：‘他们现在不需要这位子——他们一天有得是时 间。’”(奥地利) 有人说公共汽车司机不顾车上的老年乘客而任意加速，老人们很难保持身体的平衡甚至有 时候会摔倒。 就如奥地利的报告所言，老人们普遍

觉得受到了政府和社会保障部门的漠视、侮辱与无视，在商店和公共运输系统等地方受到 错误对待。老人们普遍感觉到被推向了社会的边缘。(奥地利)

D) 法律与财产虐待 法律虐待是一种发生在印度和黎巴嫩的特殊类型的虐待，尽管两个国家的法律虐待有所不 同。印度的法律虐待指的是儿媳通过婚姻法实施的虐待：

在印度，有一条法律意图保护儿媳免受姻亲的虐待。一位媳妇可以到警察局投诉说她被姻 亲虐待，则姻亲会仅仅因为她一个人的证词而被捕。然而，专题小组的参与者指出一些媳 妇利用这条法律，向警方捏造投诉，以此来虐待老人。参与者强调，通常媳妇对于老人缺 乏关心的态度才是主要的问题。(印度) 在黎巴嫩，法律虐待的发生是指没有法律保护老年人的权益，尤其涉及到继承案件。宗教 法庭负责裁决受益人的继承财产分配，但是这些法庭并不具有足够的能力解决这些案件。一个 例子是，有一个人向宗教法庭呈递了一份医生出具的关于他父亲心智不全的评估意见，而这就 足以让他剥夺他父亲的全部财产。

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“ The bus driver closed the door just before this old woman with two crutches could enter the bus. Well, he opened the door again but was angry and scolding her” (Austria) “Recently, in the street-car, some youth were sitting next to me; when some elderly persons were entering the car the young people did not offer their seats but rather said: ‘What do they want here now – they have time all day long.” (Austria) Bus drivers are said to accelerate without concern for their older riders, who find it difficult to keep their balance and sometimes fall down as a result.

As the report from Austria describes, in general, older adults feel disregarded, insulted, ignored by government or social security agencies or mistreated in shops, in public transport, etc; the general feeling is that the elderly are pushed to the edge of society. (Austria)

D) Legal and financial abuse Legal abuse was named as a particular type of abuse in both India and Lebanon, although each country has its own specific version of this. The Indian expression of legal abuse is through abuse of the dowry laws by daughters-in-law: In India, there is a law that is intended to protect daughters-in-law from abusive in-laws. A daughter-in-law can go to the police station and lay a complaint that she is being abused by her in-laws, and the in-laws are arrested on her word alone. However, the focus group participants reported that some daughters-in-law are using this law as a form of elder abuse, by making false police reports. In general, participants stressed that the lack of a caring attitude by daughters-in-law was a major problem. (India) In Lebanon, legal abuse was said to occur because there are no laws to protect the rights of older adults, particularly regarding inheritance issues. Religious courts are responsible for deciding on the division of the inheritance among the beneficiaries, but these courts are not well equipped to understand certain issues. An example was given of a person who presented to the religious court a doctor’s evaluation that his father was mentally incompetent, which was enough to deprive the father of his money.

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3.2 虐待的具体情境 A) 退休老人的社会角色 退休被认为是所有事情突然发生改变的重要时刻，尤其对男性而言。生产能力和从前的职 业角色都在此时丧失。这一主题可能反映了在一些老年人的专题小组中曾经的专业职业人员偏多 影响了代表性。虽然退休问题在大多数发展中国家的报告中出现，但是奥地利、加拿大和瑞典的 参与者并没有对此给予关注。巴西报告中的发现表明退休问题和社会排斥与虐待密切相关：

“对一个老人来说，退休了意味着将被社会系统的一部分，即政府官员所虐待。”(巴西)

在巴西要拿到第一笔养老金支票是一个漫长的过程，牵涉到“繁杂的官僚部门”，需要在 几个不同的政府办公室等很久并且在收到第一笔支票之前还要等待很长一段时间。刚刚退 休的人在这段漫长的等待期间可能会遭受严重的经济匮乏。而之后他们又会发现养老金支 票通常还不够维持他们的生存。这些都构成了政府虐待。 退休和没用被联系在一起，无论他曾经在劳动力市场当中承担何种角色。他可能在不少不 同的岗位上工作过，但根本问题是他现在的特征就仅仅是退休了。(巴西)

B) 长期护理机构(LTCI) 尽管在参与研究的国家之间老年人入住长期护理机构的比例有很大差异(在加拿大为 8-10%，在黎巴嫩不到1%)，在该环境下的老年人虐待问题还是被许多专题小组提及。 在发展中国家，将老人安置在长期护理机构中被视为是对那些非常贫穷且没有家人照顾的 老年人的最后的应对方案。对长期护理机构的感情是混杂在一起的。虽然参与者们对这些机构 感到深深的恐惧，但是他们也承认这些机构是必要的，并且在许多发展中国家里需要更多这样 的机构来安置贫穷的以及/或者被遗弃的老人。 参与者们认为是否要入住寄居机构的选择权应该给予老年人。如果其他人做出了这样的决 定，应该被视为一种虐待。一位阿根廷的参与者说道：

“把一位老人放到寄居机构中去就好比绑架了他一样。”(阿根廷) 大多数的报告中触及到了长期护理机构中虐待问题的现实。有几份报告提到需要对这些机 构有更好地保障和监督措施。

“把老人驱逐到老年人之家是种虐待。老年人之家就好像是死亡深渊的门厅。”

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3.2 Concrete contexts of abuse A) Retirement and the social roles of older persons Retirement is considered the point when everything suddenly changes, especially for men. There is a loss of productive capacity and a loss of one’s former professional or vocational role. This theme may reflect the fact that former professionals were over represented in some of the older adults’ focus groups. While the issue of retirement emerged in most of the reports for developing countries, it

“For an older person, to be retired means to be abused by part of the social system, per- sonified by government officials.” (Brazil) Receiving the first pension cheque in Brazil is a long process, involving a “burdensome bureaucracy,” long waits in several different government offices and a long waiting period before receiving the first cheque. Newly retired persons may suffer major deprivations during this waiting. Then they discover that the pension cheque is usually not enough to survive. All this is government abuse.

Uselessness is associated to being retired. It doesn’t matter what he was when active in the labor force. He might have worked in a number of different professions, bottom line he is characterized as only retired. ( Brazil)

B) Long-term care institutions (LTCI) While the proportion of older people living in LTCI varies widely among the participating countries (8-10% in Canada to less than 1% in Lebanon), elder abuse within that context was referred to by many focus groups.

In developing countries, placement into long-term care is regarded as a last response for the very poorest people with no family to care for them. Sentiments about long-term care institutions were mixed. While participants largely dreaded them, there was also an acknowledgement that they were essential institutions, and that in many of the developing countries more were needed to accommodate destitute and/or abandoned older adults.

Participants agreed that institutionalisation needs to be a choice that is made by the older person. If someone else makes this decision, it is considered abusive. A participant in Argentina expressed:

“To institutionalise an old person is like kidnapping someone.” (Argentina) Most of the reports touched on the reality of abuse in long-term care institutions. Several noted the need for more safeguards and closer supervision of these institutions.

“Deportation to homes is abuse. A home for the elderly is nothing more than an entrance hall of death.” (Austria) 34

C) 医疗护理人员作为施虐者或者受害者 医疗护理人员一直被认为是虐待问题的一部分贯穿整个报告。

“他们绝不会告诉我母亲她正在接受什么药物治疗——她对此已经失去掌握。”(加拿大) 这样的问题从仅仅没有接受足够的训练来理解老年人的问题，直到没有足够时间来听取那 些医疗护理人员明确实施虐待行为的报告。后面这个问题主要在巴西和肯尼亚的报告中指出。 肯尼亚的报告专注于基层医疗护理系统中的虐待问题，里面包括了一个又一个严重的案例：

“在某家地方医院中，医疗人员对病人又是侮辱，又是粗鲁地训斥或者推搡。”(肯尼亚) “我在某家地方医院里亲眼见到一位老妇人在买药时被要求收取超过正常价格一半的金 额。她还得等六个小时才能拿到药因为医疗工作人员都在忙着其他事情。因为她筹不到那 么多买药的钱，一位好心人帮她付了钱。即使已经有人帮她付了被故意抬高的药费，她在 四个小时以后，还来不及接受治疗就因为等得太久而去世了。”(肯尼亚) 然而，这份报告也清楚地指出了结构性因素在造就医疗护理工作人员糟糕的工作环境中所 起的作用。阿根廷和肯尼亚的报告中认为，在医疗护理人员的待遇以及他们对待老年病人的方 式上，存在着一种关联。 在阿根廷，医疗护理人员谈到了许多他们面对老年病人时会遇到的困难，并且认为这些问 题非常常见。举个例子，大部分人感到人们对老年病学这个领域怀有偏见，大家都认为这是二 流的，其他领域的医疗专家和管理层也看不起他们。他们也提到在这个岗位工资低而且会受到 老年病人及他们家属的错误对待。 所有这些经历被他们强烈地认为是一种虐待。只有极少数人说他们从业以来没有受到过错 误对待。由此产生的一个有意义的问题就是，当医疗人员感到自己被如此错误对待，他们对老 年人虐待的情况还能不能保持敏感的反应。

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C ) Health care professionals as abusers and as victims Throughout the reports, health care professionals are perceived as part of the problem.

“They won’t tell my mother what medications she is on—her control is gone”.

(Canada).

This ranges from simply not being adequately trained to understand ageing and the problems of older people, or not having enough time to listen to reports of health care professionals perpetrat- ing clearly abusive acts. The latter were mostly reported in the Brazil and Kenya reports. The Kenya report, which focused only on abuse in the primary health care system, contains one serious story after another:

“In ... District Hospital, the sick are slapped, rudely rebuked and pushed by health workers.” (Kenya) “I witnessed a case whereby an elderly woman was charged one and a half times the usual rate for medicine at ... District Hospital. She waited for six hours for the medicine as health workers attended to other issues and cases. A Good Samaritan paid for her because she was incapable of raising the required money for medication. Even after someone had paid for her the inflated charges, she waited for so long and died four hours later before receiving the medication.” (Kenya) However, this report also clearly notes the role of structural factors in creating poor working conditions for health care professionals. The Argentinian and Kenyan reports suggest a relation- ship between the treatment of health care workers and the ways in which they, in turn, treat their older patients.

In Argentina, health care professionals spoke extensively about the difficulties they experience in working with older people, which they believed were universal. For example, the majority felt that there was some prejudice against geriatrics as a field, with it being considered as second class and less qualified by other professionals and administrators. They also referred to low salaries in this speciality as well as to mistreatment by older patients and their families.

All these experiences were strongly perceived as abusive. Few claimed they had never received mistreatment in their professional lives. This raises some interesting questions about the ability of health care professionals to be sensitive to and respond to situations of elder abuse, when they themselves feel so mistreated.

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在肯尼亚，医疗护理系统高度超负荷运行，工作人员都在极端困难的环境下工作。肯尼亚 的医院里对如何对待老年病人缺少规章、政策和程序。这事实上使得医疗系统内部根本无法分 析老年病人的虐待问题并处理那些施虐者。进一步来说，这意味这老年病人们

“不得不由着医疗工作人员的性子来。”(肯尼亚) 专题小组的成员们认为肯尼亚的医院中充斥着腐败和利益冲突，一部分的原因可能是因为 工作环境是如此的糟糕。一家医院的一些护士承认说，她们之所以“对那些付不起钱的老年病 人不友好”的一部分原因是因为，她们想要改善自己的工作待遇和环境只能依靠那些能出得起 不少钱的病人。所以她们是把那些贫穷的老年病人和自己作为医疗人员所遭遇的错误对待直接 联系在了一起。

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In Kenya, the health care system is grossly overburdened and staff work under extremely difficult conditions. There is a lack of norms, policies and procedures for handling older patients in Kenyan hospitals. This makes it virtually impossible to analyse the abuse of older patients within the system and to deal with perpetrators. Furthermore, it means that older patients are

“vulnerable to the whims and moods of staff.” (Kenya).

Kenyan hospitals were perceived by the focus groups participants to be rife with widespread corruption and conflict of interest, perhaps partly because the working conditions are so poor. Some of the nurses at one hospital confessed that part of why they “do not look kindly upon older patients who have trouble settling their bills” is because they realize that their working conditions will only improve with larger revenues from patients. Thus they directly link indigent older patients with their own mistreatment as health care professionals.

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D) 具体文化差异对虐待的影响 尽管大多数老年人虐待的主题都有各自特殊的文化背景和表达方式，但是在报告中出现了 一些特定的主题与具体的文化环境有密切联系。虽然这些主题只是在某些国家报告中出现，有 可能其他国家也有没有被清晰识别出来的类似的虐待。 对巫婆的指控是以上主题的一种，在最近世界卫生组织在莫桑比克(也包括一些其他南撒 哈拉非洲国家)指导的一项研究中有所报告。作者报告了她所在国家的一些老年人虐待的极端 案例，包括针对老年妇女的对巫婆的指控。(Da Silva 2002) 儿媳作为老年人虐待的一类重要施虐者在以下三个国家的报告中被提及：印度、黎巴嫩和 奥地利。在黎巴嫩，几乎所有的女性参与者都提到了婆婆和媳妇之前的争端。讨论涉及到了婆 媳的互相猜忌以及各种家庭矛盾。这些矛盾导致了各种形式的虐待和忽视，包括身体虐待或者 有时候违背姻亲的意愿将他们送入公共寄居机构。

许多参与者报告说姻亲关系通常是不友好的并且缺乏温馨。尤其是，受到婆婆长时间的欺 压会导致媳妇在之后的报复行为，特别是当媳妇掌管了家里的照料工作之后。(奥地利) 宗教问题并没有被给予关注，不过一些报告中对它们的简要描述或许预示着一个以后的研 究可以探索的话题。 在黎巴嫩，宗教因素有利于避免老年人虐待，因为有强有力的宗教命令要求尊敬和照顾老 年人，尤其是自己的父母。在肯尼亚，宗教机构常常承担了关怀贫困老人的义务。 在肯尼亚，传统医者早于现代医学的出现并且是宗教活动的重要组成成分。这些角色一般 由老年人传承。传统医者为那些资金不足的、穷人看不起的并且充斥着腐败和虐待的医疗护理 系统提供了一种替代。肯尼亚参与者这样报告说：

“我有14年没有去过医院了。它太贵了。我大部分的药品都是从医者那里得来的。他给的 价格比较低而且可以商量付款期限。”(肯尼亚) 这些医者是对医疗护理系统的重要补充，在肯尼亚报告的建议中也是这么指出的。它建议 加强两种医疗系统的合作，政府制定规范并且协调传统医者之间的关系。对传统医疗资源的利 用可能为大众提供一个新的选择，同时也要提防不道德的医者可能造成的虐待。

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D) Culture-specific influences on abuse Although most of the themes relating to elder abuse have a culturally specific context and form of expression, certain themes emerged from the reports as being particularly linked to certain cultural contexts. Although these are themes that were only mentioned in certain of the reports, it may be that other countries also have fainter echoes of some of these manifestations of abuse which were not specifically mentioned Witchcraft accusations can be added to the themes above, as reported in a recently WHO-conducted study (also reported in other Sub Saharan African countries) in Mozambique. The author reported extreme cases of elder abuse in her country consisting of accusations of witchcraft against older women (Da Silva 2002).

Daughters-in-law were specifically mentioned as important perpetrators of elder abuse in three of the reports: India, Lebanon, Austria. In Lebanon, the conflict between mothers-in-law and daughters-in-law was almost universally mentioned by the female participants. There is a lot of mutual jealousy, and various kinds of family dynamics were discussed. These dynamics result in various forms of abuse and neglect, including physical abuse and sometimes placement of the in-laws in institutions against their will.

Many participants reported in-law-relationships as being often strained and characterised by an absence of warmth; in particular, life-long oppression of women by their mothers-in-law can result in revenge actions later in life, especially when the daughters-in-law have take over the carer’s role. (Austria) Religious issues were not focused upon, but brief references to them in a few of the reports may indicate a topic to be explored in susequent studies.

In Lebanon, religion is seen as a protective factor for elder abuse, because of strong religious injunctions of respect and care for older adults, particularly one’s parents. In Kenya, religious institutions are often those who care for destitute older adults.

In Kenya, traditional healers predate modern medicine and are key elements of religious practices.

These roles are generally carried out by older people. Traditional healers provide an alternative to the health care system, which is underfunded, inaccessible to those who are poor and considered rife with corruption and mistreatment. Kenyan participants reported:

“I have never been to hospital in 14 years. It is too expensive. I get most of my medicines from the healer. His prices are lower and payment terms are negotiable.”(Kenya) These healers offer an important alternative to the health care system, and this is reflected in the recommendations of the Kenyan study, which propose increased collaboration between the two systems of health care and government regulation and coordination of traditional healers. While use of traditional healers has the potential to provide an empowering choice to this population, it also has the potential for abuse by unscrupulous healers.

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4. 启示——老年人虐待的预防策略 4.1 专题小组参与者们提出的策略 参与者们提出了非常多样的预防与干预策略。而这些不同国家的建议同时具有很强的共 性。专题小组所提出的主要的策略可以分成以下一些类别：

・ 教育促进了解：这是一个普遍的建议并且包涵了一系列不同的方面。需要引导人们将老年 人看成是社会的积极贡献者，善意地理解他们。需要鼓励人们与老人们建立更亲密的关 系。这样的教育需要很早，从小学就开始。同时也应当让大众了解到老年人虐待问题的发 生。老年人也需要了解这些问题以及他们所拥有的权利，并且明白如何获取可用的社会服 务与社会资源。

・ 建立跨代关系：这与第一类建议有所关联，强调的是鼓励各代人之间建立更亲密与积极的 关系。老年人所处于的被社会隔离与忽视的状态，需要通过与其他人建立跨代关系来打 破。另外，大多数报告谈到了年轻人对老年人所显示出来的不尊敬以及所持有的负面的态 度与价值观。所有这些问题需要通过教育以及其他不同的方法来解决，以建立积极的跨代 关系。

・ 训练专业人员：参与者们常常提到，医疗专业人员在关于老龄化、老年人以及老年人虐待 方面缺乏必要的知识。需要广泛地提供训练指导，帮助医疗护理人员懂得识别老年人虐待 的征兆与迹象以及如何干预这类事件。

・ 授予老人权利：一些报告强调了老年人为自己的权益谋求自主行动的迫切需要。许多参与 者强烈地感受到，老年人有这种需要去行使自己完整的公民权利并且主张自己的利益。在 瑞典，由老年人组成或面向老年人的组织协会被认为是解决这类问题的重要方式。

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4. Implications—strategies for the prevention of elder abuse 4.1 Strategies proposed by the focus groups participants Participants proposed a wide variety of prevention and intervention strategies. There was a strong convergence across countries in terms of these recommendations. The major strategies that emerged from the focus groups can be grouped together as follows: •

•

•

•

Awareness and education: this was a universal recommendation and covered a number of different areas. People need to be educated to perceive older adults more favourably as positive contributors to society. They need to be encouraged to form closer relationships with older adults. This education needs to start very early, in primary school. The general population also needs to be aware that elder abuse happens and is a problem. Older adults need to be aware of the problem and of their rights, as well as available services and resources.

Intergenerational relationships: this is linked to the first recommendation and places an emphasis on the need to encourage a closer and positive contact between generations. The social isolation and neglect of older adults needs to be broken, through intergenerational relationships, among others. Also, most of the reports mentioned the perceived negative attitudes and values of the younger generation and the disrespect they show to the older generation. All of these issues need to be addressed through education and through different programs to build positive relationships.

Training of professionals: participants often mentioned lack of knowledge on the part of health professionals about ageing and older people, and also about elder abuse. Providing training so that health care professionals can recognize the signs and symptoms of elder abuse and how to intervene needs to be made widely available.

Empowerment of elders: some reports emphasized the need for older adults to act for themselves and on their own behalf. Many participants felt strongly about the need for older adults to exercise their full citizenship rights and advocate for their own interests. In Sweden, organisations and associations of and for older people were seen as important ways of addressing the problem.

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・ 转换媒体角色：媒体常常被指责为制造社会上老年人负面形象的一个根源。与媒体联手行 动，改变这些负面形象，并且提升和引导大众对于老年人虐待问题的认知是一个重要的方 面。

・ 修建娱乐设施：老年人的孤独感是一个贯穿绝大多数报告的主题。缺少娱乐设施，尤其在 发展中国家是一个问题。大多数国家都提到需要更多的娱乐设施。

・ 解决结构性问题：这一类建议相比其他一些建议来得不那么直接，主要集中在修订对老年 人的保护性法律、改善医疗计划以及类似的结构性问题方面。肯尼亚报告主张吸引非政府 组织(NGO)作为合作伙伴来推行这些改变。

・ 研究老年虐待：发展中国家的许多研究者发现他们国家对老年人虐待问题知之甚少。专题 小组的参与者们也有此共鸣，建议呼吁更多研究来获取自己国家关于这方面的信息资料。

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•

•

•

•

Role of the media: the media was often blamed as one of the sources of the negative images of older adults in society. It was seen as important to work with the media to change these negative images, to raise awareness and to educate the population about elder abuse.

Recreation facilities: the loneliness of older adults was a persistent theme throughout most of the reports. One problem, especially in developing countries, is the lack of adequate recreation facilities. The need for recreational facilities was mentioned by most of the countries.

Structural solutions: these suggestions were less direct than some of the others, but centred around the need for strong protective laws, improved health care plans, and similar structural issues. Kenya argued for the need to involve NGOs as partners in advocating for some of these changes.

Research: most of the researchers in developing countries noted that there is very little known about elder abuse in their countries. This was echoed in the recommendations by focus group participants, who called for more research to obtain more information about the problem in their country.

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4.2 项目组的策略与行动建议 世界卫生组织与国际老年人虐待预防网络选择基层医疗护理环境作为实现全球策略的过程 的第一步，因为让基层护理工作人员了解老年人虐待问题对预防和管理这类问题至关重要。 在2001年10月11-13号于日内瓦举行的世界卫生组织国际会议上，参与这个项目的顾问 团队和各国的研究协调员达成一致意见，将以下的九个策略作为他们全球联合应对老年人虐待 问题的部分目标：

・ 开发一套关于老年人虐待的教育计划，用以培训基层护理专业人员 ・ 在发展中国家开发一套老年人虐待筛查与评估工具，给基层护理专业人员试用 ・ 在发展中国家开发并传播一个研究方法工具包，扩展关于老年人虐待的研究 ・ 建立一个关于老年人虐待的小型数据库 ・ 在老年人组织与年轻人组织中推广跨代试点研究 ・ 建立全球资料库积累预防老年人虐待的有效的实践经验 ・ 通过提高大众对于老年人虐待问题的普遍危害性的了解动员整个公民社会 ・ 促进政策改善解决老年人虐待问题 ・ 确保研究发现通过科学期刊顺利传播 4.3 结论——前进的道路 这篇报告翻开了一条注定漫长而艰辛的旅程的开头几页篇章。尽管说无法代表所有的老年 人，但是起码它可以分享其中一些人的观点。这些观点会使人感到一定程度的震惊与悲伤，同 时可以指望，将会引起反思、行动与改变。 达成的策略和行动计划确实提供了一些答案，但不可避免地提出了更多的问题。这个过程 将不仅仅提升人们对老年人虐待的认识程度，还将开始为老年人追求更多权利，甚至会导致社 会的变革。老年人不奢求比他人拥有更多，他们需要的是平等——作为人的基本权利。 让如此多的生命可以享受长寿的生活可以说是二十世纪最伟大的成就之一。让老人可以免 受虐待和暴力的侵扰而活得具有尊严一定是二十一世纪所有社会的目标。这一切从尊敬开始， 如同那位老年参与者所说：

“尊敬比食物和饮料更宝贵。”

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4.2 Strategies and recommendations for action by the project team WHO and INPEA, in stating the process of developing a global strategy, chose the primary care context as involving primary care workers aware of the problem of elder abuse being crucial in preventing and/or managing the issue.

At the international meeting held at WHO in Geneva 11–13 October 2001, the advisory group and the national coordinators of the countries participating in the project agreed to pursue the following nine strategies as part of their joint global response to elder abuse: • • • • • • • • •

To develop an education package on elder abuse for the training of primary health care professionals To develop and pilot a screening and assessment tool for primary health care professionals in developing countries To develop and disseminate a Research Methodology ‘Kit’ to expand the study of elder abuse in developing countries To develop a Minimum Data Set on elder abuse To promote intergenerational pilot studies of older and younger people in their organisations To develop a global inventory of good practice in the prevention of elder abuse Tomobilizecivilsocietythroughraisingawarenessofthewidespreadmagnitudeofelderabuse To promote policy change to address elder abuse To ensure dissemination of the research findings through scientific journals

4.3 Conclusions—the way forward This report turns the first few pages in what promises to be a long and complex journey. While it cannot claim to speak for all older people, it can share the perceptions of some. These percep- tions will shock and sadden in equal measure and will, one can hope, lead to reflection, action and change.

The strategies and action plans agreed will give some answers but inevitably pose further ques- tions.

This process, however, will not only raise awareness but will start the journey towards greater empowerment of older people and, maybe even, societal change. Older people do not want more than others, they want equality—a human right.

For so many to live to be old is one of the most remarkable achievements of the twentieth cen- tury.

To be old and live in dignity free from all forms of abuse and violence must be a common goal for all societies of the twenty-first century. It all starts with respect as in the words of one of the older respondents:

“Respect is better than food or drink”.

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参考文献 Action on Elder Abuse (AEA) Bulletin, May-June 1995, No 11. Published by AEA, Astral House, 1268 London Rd, London SW116 4ER, UK Ogg J,Bennett GCJ, (1992) Elder abuse in Britain, British Medical Journal, 305:998-9 Baker AA Granny Battering. Modern Geriatrics 1975; August:20-4 Burston G, Do your elderly patients live in a fear of being battered? Modern Geriatrics 1977;7:54-5 Da Silva Terezinha, Elder abuse in Mozambique, WHO, 2002 Pillemer KA, Moore DW(1989) Abuse of patients in nursing homes: findings from a survey of staff, Gerontologist, 29(3):314-320 Podnieks E, National survey on the abuse of the elderly in Canada, 1992, Journal of Elder Abuse and Neglect, 5(2):27-36 United Nations (1998). Population Database (up-dated)

各国研究协调员 阿根廷：Lía Daichman, INPEA, Universidad de Belgrano, Buenos Aires 奥地利：Josef Hörl, Institute of Sociology, University of Vienna and Alexandra Werba, Federal Ministry of Social Affairs and Generations, Centre for Ageing Policies and Populations 巴西：Laura Machado, INPEA, Institute of Gerontology Candido Mendes University (UCAM), Rio de Janeiro 加拿大：Elizabeth Podnieks, INPEA, School of Nursing, Ryerson University, Toronto 印度：Shubha Soneja, Help Age India, New Delhi 肯尼亚：Munyama Pension, HelpAge Inernational-Africa Regional Development Centre and HelpAge Kenya 黎巴嫩：Tammam Tayara, Social Welfare Institutions, Omr al Madid Institution for the elderly, Beirut 瑞典：Britt-Inger Saveman, Department of Health and Behavioural Sciences, Kalmar University, Kalmar

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References Action on Elder Abuse (AEA) Bulletin, May-June 1995, No 11. Published by AEA, Astral House, 1268 London Rd, London SW116 4ER, UK Ogg J, Bennett GCJ, (1992) Elder abuse in Britain, British Medical Journal, 305:998-9 Baker AA Granny Battering. Modern Geriatrics 1975; August:20-4 Burston G, Do your elderly patients live in fear of being battered? Modern Geriatrics 1977; 7:54-5 Da Silva Terezinha, Elder abuse in Mozambique, WHO, 2002 Pillemer KA, Moore DW (1989) Abuse of patients in nursing homes: findings from a survey of staff, Gerontologist, 29 (3): 314-320 Podnieks E, National survey on the abuse of the elderly in Canada, 1992, Journal of Elder Abuse and Neglect, 5(2): 27-36 United Nations (1998). Population Database (up-dated)

Coordinators of the national studies Argentina: Lía Daichman, INPEA , Universidad de Belgrano, Buenos Aires Austria: Josef Hörl, Institute of Sociology, University of Vienna and Alexandra Werba, Federal Ministry of Social Affairs and Generations, Centre for Ageing Policies and Populations Brazil: Laura Machado, INPEA, Institute of Gerontology Candido Mendes University (UCAM), Rio de Janeiro Canada: Elizabeth Podnieks, INPEA, School of Nursing, Ryerson University, Toronto India: Shubha Soneja, Help Age India, New Delhi Kenya: Munyama Pension, HelpAge International–Africa Regional Development Centre and HelpAge Kenya Lebanon: Tammam Tayara, Social Welfare Institutions, Omr al Madid Institution for the elderly, Beirut Sweden: Britt-Inger Saveman, Department of Health and Behavioural Sciences, Kalmar University, Kalmar

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