Chapter 12. Elder Abuse Risk Factors and Intervention Strategies: Perspectives of Korean Older Immigrants

The percentage of older people is increasing worldwide (United Nations, 2020), and concerns about elder abuse are also growing. The WHO (2017, par. 4) defines elder abuse as “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. Elder abuse can take the form of financial, physical, psychological, and sexual abuse, or be the result of intentional or unintentional neglect.” In Canada, the prevalence of elder abuse is about 7.5 percent (National Initiative for the Care of the Elderly, 2015). However, elder abuse in immigrant communities remains largely underreported (Moon & Benton, 2000).

Previous studies have identified a range of factors that contribute to elder abuse. With age, many people are vulnerable to physical, mental, and cognitive health challenges, including decreasing mobility and declining general health, all of which increase the demand for health care and social services (Walsh et al. 2010). Immigrant older adults with language barriers often rely on others, primarily family members, to access required services and/or to receive assistance in care. However, adult children themselves are often working immigrants who may be struggling to adjust to Canada’s culture and lifestyle, making it difficult for them to access the services and resources required to help their aging parents (Chung, 2016). For some immigrants, acculturation may involve additional challenges, specifically related to reframing the collectivistic mindset to accommodate a more individualistic way of life (Chung, 2016). Some scholars have observed intergenerational differences in cultural expectations regarding filial piety and treatment of elderly parents and grandparents (Guruge, Tiwari, & Lucea, 2010). Unresolved cultural differences and misunderstandings can lead to family conflicts and situations of neglect.

Some studies have developed intervention strategies to address elder abuse (Burnes et al. 2021; Ploeg et al. 2009). Some of these have included immigrants; for example, Dong and colleagues (2014) found that increasing psychological wellbeing facilitated help-seeking behaviours among older Chinese immigrants experiencing abuse. However, the body of Canadian research on elder abuse risk factors and prevention strategies in immigrant communities is limited, especially with regard to the relatively recent and small Korean community.

The Korean immigrant community in Canada is the fourth largest Korean diaspora globally, after the United States, China, and Japan (Bergsen & Choi, 2003). It shares the broader Confucian tradition with other East Asian immigrant communities, but it also has a distinct history and customs, norms, beliefs, and values (Armstrong, 2021), all of which may influence perspectives on elder abuse. Similar to other immigrant counterparts in Canada, Korean older adults face many settlement challenges that increase their risk of experience of abuse. We explored the risk factors for elder abuse in the Korean immigrant community in the Greater Toronto Area. Our specific aims were to: (1) identify most frequent and important risk factors that create situations of elder abuse as perceived by older Korean immigrants, (2) explore interventions that aim to prevent abuse and are appropriate to the community, and (3) examine gender differences in the perception of risk factors and appropriateness of the interventions.

Theoretical Framework

This study was informed by an intersectionality framework (Guruge & Khanlou, 2004) and an ecosystemic framework. The ecosystemic model (Heise, 1998; Waller, 2001) can help clarify how individuals are situated within and influenced by individual-, micro-, meso- and macro-systems, and how elder abuse is affected by the dynamic interplay of multilevel influences (Guruge & Khanlou, 2004). An intersectionality lens also helps to contextualize each individual’s unique perceptions of risk factors and appropriate interventions in relation to their social identities.

Methods

We used a mixed-method study design.

In Phase 1, we used a quantitative approach to identify what risk factors were perceived as most frequent and important in leading to elder abuse in the Korean community. Specifically, we provided older participants with a list of thirteen elder abuse risk factors that we had identified from previous research and asked them to rate the factors, on a scale of 0–4, based on how they perceive each factor’s frequency of occurrence and importance in contributing to elder abuse. Next, participants engaged in semi-structured group interviews to discuss the rationale for their choices.

In Phase 2, we used a quantitative approach to identify what interventions were perceived as appropriate in preventing elder abuse in the Korean community. Participants were given a description of each intervention that highlighted what the intervention is about and how it is delivered. Then, participants were asked to rate (on a scale of 0–4) the appropriateness (i.e., suitability) to the community, of fourteen interventions: eight targeting older immigrants and six targeting abusers. Next, participants engaged in semi-structured group interviews to discuss the rationale for their choices.

After obtaining research ethics approval from all affiliated universities, we recruited older women and men who met the following criteria: 60 years or older, born outside of Canada, self-identifying as belonging to the Korean community, and personal experience of elder abuse or know other Korean older adults who have experienced it. Participants were recruited using word of mouth and/or referral through our community connections. The group interviews were held in private rooms, at times and locations that were convenient for participants, such as a university, recreational centre, or church.

Bilingual research assistants obtained informed written or verbal consent from all participants and then asked each participant to complete a brief socio-demographic questionnaire. Next, the research assistants asked each participant to rate the frequency and importance of thirteen risk factors for elder abuse (in Phase 1) and the appropriateness of fourteen intervention strategies (in Phase 2), and then to engage in a group interview to discuss their ratings and rationales.

Demographic information and rankings on the risk factors and interventions were analyzed using SPSS. We used descriptive statistics (frequency, measures of central tendency, and dispersion) to analyze demographic information, and mean scores for each risk factor in terms of frequency and importance and for perceived appropriateness of interventions. Independent sample T-tests were used to compare mean rating of older women and men. Additional Cohen’s d tests were performed to determine the effect sizes of gender-based differences in risk factor ratings.

Audio-recordings of group interviews were transcribed and translated into English. The transcripts of each group interview were analyzed separately, and then the emerging results were compared and contrasted across groups and genders using an intersectionality lens and an ecosystemic framework.

Phase 1 Results

In total, 49 older men and women completed the rankings and participated in seven semi-structured group interviews. Most had arrived in Canada before 2000, and more than 75% had children residing in Canada. All spoke Korean as their first language. The following sections present the quantitative findings along with excerpts from group interviews.

Risk Factor Ratings

Table 12.1 lists the ratings for the perceived frequency of occurrence for each factor. Overall ratings hovered around the low-to-moderate spectrum of the scale. In general, older women and men identified social isolation, lack of English knowledge, financial dependence, and racialized, cultural, or ethnic group status as risk factors that occur frequently in situations of elder abuse. Women tended to rate advanced age, physical dependence on others, and emotional dependence on caregivers as risk factors that occur frequently. However, these gender-based differences were minimal, and these risk factors were not rated as very frequent.

Table 12.2 lists the ratings based on the perceived importance of risk factors. Participants identified social isolation, lack of English knowledge, and financial dependence as the most important risk factors. Gender-based differences were more apparent in importance ratings compared to frequency ratings. For example, compared to older men, older women rated physical dependence on others and emotional dependence on caregivers as important risk factors.

Qualitative results: Risk Factors for Elder Abuse

Based on our analysis, the top four risk factors for elder abuse in the Korean immigrant community were: communication challenges and language barriers, financial vulnerability, social isolation, and cultural and intergenerational differences.

Factors Important to Older Women

Communication challenges and language barriers:

Language limitations prevented Korean older women from accessing resources and building social connections, and significantly compromised their independence and ability to advocate for themselves.

It really is a systemic abuse against older immigrants who cannot speak English. Without this, we cannot fully access the services that are available for all Canadians. We would not be able to receive help and support in critical situations because of the language barrier.

 

Being unable to speak and understand English makes me feel tragic, because it makes me inferior in the society. Lacking English knowledge and skills puts me at risk for being treated with disrespect.

At the micro level, the Korean custom of nunchi (in which needs are not explicitly mentioned but are expected to be met) frequently led to miscommunication and misunderstanding between caregivers and older immigrants and reported feeling neglected by their children’s ‘individualistic mindsets.’ Many of our participants noted that they had difficulty accessing professional support services due to lack of awareness, as well as inadequate language skills to complete the application process for available programs.

Financial vulnerability:

Older women spoke about their experiences of and worry about financial exploitation and neglect. Korean immigrants often bring assets with them, and our participants were worried about their finances being taken away by family members or others. The following excerpts capture some of these ideas.

We have seen many incidents where older immigrants’ pension gets taken away by their children or grandchildren. In fact, anyone who is close to the older immigrants can fool them and take their money. When you become too old, your ability to manage your own finances declines. These things really frighten me, as my children do not live in Canada.

Some participants who had been sponsored by their adult children experienced even more financial vulnerability, because they were typically not eligible to receive government-funded benefits designed to help older persons. Without adequate language skills and limited finances, some participants felt enormous pressure to provide childcare which fueled disputes within multigeneration families, especially between mothers/-in laws and daughters/-in-law regarding the unspoken distribution of domestic responsibilities.

If you live with your children and grandchildren, you have to look after the grandchildren twenty-four hours a day. You can’t just ignore them. For example, when your daughter-in-law comes home from a long day of work, you can’t just sit there and do nothing. You at least have to prepare dinner before she comes.

Some older women reported that their adult children saw them as a burden once they could no longer contribute to the household.

Social isolation:

Some participants wished to be closer to their grandchildren, but some older women did not want to live with family, fearing that they would be automatically expected to provide free childcare for the grandchildren and take on all domestic responsibilities while their adult children worked full-time. Participants also shared their desire for more culturally and linguistically accessible services and programs. Many stressed the need for long-term care facilities with Korean-speaking staff within the Greater Toronto Area.

Older immigrants living in this nursing home say that they are being neglected and abused because the staff will pretend not to understand when the attempt to express their needs in broken English. Until we go to visit, they are basically “left alone” in a vulnerable state, so they live in great belittlement and discrimination.

 

The food that the senior homes serve may not be the type of food that they are familiar with. They also have a difficult time communicating because of their inability to speak English. Even after being admitted to senior homes, it does not solve all their problems. They still struggle with isolation and find their lives in senior homes very difficult to accept and adapt to.

Overall, our participants noted that they relied heavily on their children (who may be their abusers) as their main source of social connection and to navigate formal social support resources. Without culturally appropriate housing options for older persons, participants were forced to remain with their adult children who often have multiple or full-time jobs.

Patriarchal beliefs, values, and attitudes:

Participants reported that patriarchal beliefs and values shape older men and women’s lives, which increase the vulnerability of older women:

Most women in our generation often just submit to their husbands and think of themselves as the dependents.

 

I am not getting [the total amount]. Just a partial payment from the old age pension. I asked my husband to give me access to the bank account so I can take out some money. But he confronted me why I need the money. I always have to ask for his “approval” for my portion of the money.

 

At the macro level, many of our female participants were grateful for any government-sponsored benefit programs they were able to access as they relied heavily on such assistance for some guaranteed income, apart from what their husbands gave them.

Factors Important to Older Men

Language barrier:

Most participants reported the impact of their lack of fluency in English as a significant factor contributing to many aspects of their lives which contribute to situations of elder abuse. These aspects ranged from social isolation to dependency on others to manage their declining health.

 

Toronto is a multicultural city, and to be able to at least greet your neighbors every morning, you need to speak English. Because communication isn’t possible, they can’t get into in-depth conversations with one another. These things can’t be helped. Having aged, it’s really not easy.

 

Participants shared their concerns over increasing dependency on others to navigate support resources and programs due to limited English proficiency and declining physical and mental health, as well as broader ageism.

Financial vulnerability:

Our participants noted that many of their first-generation children struggled as they settled in Canada and often asked parents to support them financially with their retirement savings from Korea. Parents who agreed to support their children tended to suffer from financial vulnerabilities such as being unable to afford rising healthcare costs and other support services needed in later life.

I’ve been in Canada for thirty years and counting. Canada is one of the top prosperous countries, where people can live the best lifestyle. But at the same time, there’s a huge disparity. Not everyone is so well off to enjoy that kind of a lifestyle. Older immigrants who are very old and not financially well off, there’s blatant disregard for them.

 

They reported that the restrictions regarding old age benefits and the sponsorship expectations of financial dependency on their children were significant barrier to their independence from their children.

Social isolation:

Some participants commented on the detrimental effects of people’s indifference towards older people’s social isolation, linking this experience with the onset of depression. The fragile emotional state that results from feeling socially isolated was noted as resulting in increase in vulnerable to abuse.

With this indifference towards older immigrants, the older immigrants lose their ability to interact with others and become less empowered due to loneliness and isolation. The more their independence falters, they eventually develop depression. They would lose the power to react the way any logical person would, to those who perpetrate elder abuse against them— because they are so weakened from the isolation and indifference…

 

Several participants reported being neglected by their adult children or others. They also noted that Korean culture stresses the importance of collectivism – where harmony with others is considered more important than self-protection – and therefore, feared reporting abuse that might bring harm to their family members.

Patriarchal legacy:

Our participants referred to tasks that are traditionally managed by men, such as asset management. Unequal distribution of inheritance among children was noted as creating tension within the family unit. Many participants emphasized the importance of retirement planning and preparing a safety net for the later years to protect against becoming financially dependent on children, commenting that being burdensome can overwhelm caregivers, which in turn can lead to elder abuse. Older men reported feeling that their authority diminished with age and as a result of the transition from a life in Korea to one in Canada. Many older men experienced conflicts with their spouses related to gender role reversal. Older men without an income became completely dependent on their wives and children to cook and take care of them, resulting in low self-esteem and diminished authority at home. Limited English skills and inability to advocate for themselves also exposed them to experiences of racism and diminished their social status outside their homes.

Phase 2 results

A total of 36 older women and men participated in Phase 2. More than three-quarter of these participants had come to Canada prior to 2000: most had come to Canada as either skilled workers, dependents of skilled workers, or as sponsored parents/grandparents. The following sections present the quantitative results along with excerpts from the group interviews.

Intervention Strategies Ratings

Participants rated the appropriateness of fourteen elder abuse interventions to the Korean community. The mean score for women and men as well as the total sample are Table 12.3.

Community outreach programs, information about outreach programs, social support interventions, case management, and psychoeducation (social support interventions) emerged as the most appropriate interventions. Significantly more gender-based differences were observed in the ratings for appropriateness: older women rated psychoeducation, information about outreach programs, family mediation, and referral to psycho-social counselling or support as much less effective compared to older men.

Qualitative Results: Interventions to Prevent Elder Abuse

Interventions Preferred by Older Women

Our female participants favored psychoeducation because it would provide opportunities to speak with a professional about healthy aging, risks that lead to abuse, and assistance with navigating resources within the community. Most indicated they would feel more comfortable sharing personal information with a professional rather than with a friend or their children, noting that they expected a high level of advice from a professional – and also that seeing a professional would prevent judgement and worry that would often come from friends and children.

Some participants said that in their generation it was normal for husbands to abuse their wives, and that this kind of program would be useful to educate the population on what elder abuse is, and how to promote healthy relationships.

Korean culture can be somewhat patriarchal. Some men would beat up their wives, and these women would just accept that this is the way it is and not make a big deal out of it. But through educational workshops like this, we can become aware that this is abuse.

Although psychoeducation was seen to have advantages, some participants noted concerns about the availability of Korean professionals to deliver such programs, as well as older adults’ ability to access them:

There are many who really want mental health support. There is a lot of aging Korean immigrant population in Toronto who can’t find the service providers [who can speak Korean]. We wouldn’t even know where to go to find these individuals.

Our study participants also felt that a community outreach program would be effective in assisting older immigrants with daily living activities if bilingual Korean outreach workers can be available. One of the younger participants mentioned that she was in a “sandwich generation” because she could speak English, and noted that many people mistakenly think that younger Korean Canadians who speak English do not need outreach workers who speak Korean. Language emerged as a prominent barrier across all focus groups.

I think the best feature of this intervention is the bilingual outreach worker. The fact that you can speak your needs to someone in the language you feel comfortable with can be very helpful. It develops trust through in-person interaction during visitations. I think many lonely older immigrants appreciate people visiting them.

Based on their different beliefs, upbringing, and the language barrier, our participants were concerned about their limited relationships with their children and grandchildren. They saw the community outreach program as an opportunity to interact with the younger generation. One commented that “when younger people visit older adults, they can learn from one another and benefit mutually.”

Another (relatively younger) participants vouched for the effectiveness of this kind of program despite the outreach workers not being Korean. She noticed that her elderly mother become more enthusiastic when her personal support workers (PSWs) arrived, and her English also improved.

She needs assistance at her home so she had to become friends with her personal support workers (PSWs). They visited her every day. Koreans tend to keep their house very clean. They don’t like to have strangers coming into their house either. However, for my mom, she cannot get by without the help of PSWs. I even witnessed my mom’s English improved after receiving regular support from her PSWs. My brother and I cannot see her everyday as we have our own work.

Our female participants also stressed the need for more information about outreach programs to help increase access. Most felt that church served as a central hub for information sharing and that any information shared outside of church was confusing.

Korean immigrants belong to some immigrant church, even if they are not Christians. Korean churches are where you can obtain information and network to find out more about what’s available.

Most of our female participants had limited knowledge of English, so having a list of services made it much easier to navigate resources to meet their needs.

If we could speak English, we can seek help ourselves. Anywhere. Because of this language barrier, we feel isolated. If I were younger, I will go out and learn English. But now I am aged and everything becomes that much harder physically and emotionally. We become more vulnerable ourselves to abuse.

I think having translated information for older immigrants would be very helpful, especially for those of us who struggle with English.

Participants highlighted the importance of addressing the language barriers across all intervention strategies.

Interventions Preferred by Older Korean Men

Most male participants felt that English as a Second Language (ESL) classes would be a good intervention to help reduce elder abuse in the community. They felt ESL classes would help address the communication gap with their grandchildren, and thereby improve their relationship.

My grandchildren were embarrassed to have me in front of their English-speaking friends. We were eating watermelon. My grandson came over with his friends and told me to go back in the room. This is a sad reality.

Some commented that learning English would also empower them to do daily activities on their own.

It is really embarrassing that sometimes I get overwhelmed ordering a simple cup of coffee at a coffee shop. They ask me so many questions about what to include and I do not understand.

Some commented that they had worked hard when they first arrived in Canada, so they had very little opportunity to learn English: being a financial provider was a trade-off for bettering their social conditions later in life.

You are stuck in your convenience store all day [many first-generation Korean immigrants run convenience stores]. When do you get to breathe in fresh Canadian air people are talking about? I don’t understand. All I could breathe in was beverage fridge cooling air and run the cash register. At the end of the day, I would see my nose snot that turned black due to dust. Seriously, this is the reality for the first-generation Korean immigrants. So when do you have the time to learn proper English?

As with female participants, male participants also favored a community outreach program, stressing the need for translated lists of information for those with language barriers. Some commented that this would allow them to be more independent – and that they would not have to annoy their children for information.

They look down at us by saying, “You lived here for more than forty years. You don’t even understand something like this?” This kind of treatment really discourages us from asking our children for help with translation. I rather ask strangers but not my children.

Another commented that this kind of program would make it easier to access information and ensure privacy when seeking help.

Most community-dwelling older immigrants these days have access to a cell phone. We can receive texts and make phone calls. So, mobile apps can be a safe place to receive continuous updates on available resources in Korean. This method … is accessible to anyone who has access to a working cell phone.

Some participants stressed the need to learn basic English and computer skills to access websites.

We could not have much education because we were busy putting food on the table. However, we can learn simple English phrases used in everyday life, as well as master basic computer skills like sending and receiving emails. Having these essential skills would protect one from becoming abused.

The majority of participants felt that inadequate English skills leads to a lack of knowledge about human rights, as well as dependence on children for information, both of which put elders in a vulnerable position.

Male participants also liked the idea of a peer-support program in which older immigrants sign up to volunteer and receive training on how to check on the needs of other older immigrants and socialize with them. One commented that this program could help protect mental health, especially for those who are socially isolated:

If you do not have regular conversation with people, your brain deteriorates as you age. If you live alone, it’s detrimental. Living alone is worse than dying. … Even if there is a risk of you falling on the street, older people should get out and be socially active. If you do nothing, you become sedentary. This is why older people must have friends as they age.

Some participants said that they preferred younger volunteers rather than peer-support:

I think it is a lot better for the younger people to volunteer. I think peer volunteers can be a bit awkward, am I not right? You may feel a bit down because you see a peer who is healthy and more mobile than you are. You may feel inferior.

Many of our participants also noted that they felt distant from the younger generation, and this kind of peer-support program could connect them with younger Koreans.

Discussion

Limited language proficiency, financial dependence, social isolation, and cultural and intergenerational differences emerged as the most salient risk factors for elder abuse.

Our study participants confirmed that lack of English language skills increased dependence on caregivers, especially financial dependence: family disputes over the distribution of inheritance were a noteworthy risk factor. Cultural differences, coupled with differences across three generations (grandparents, parents, grandchildren), increased the potential for elder abuse due to the inevitable miscommunications and unmet expectations among family members living together with different worldviews. Family conflicts were also fueled by significant life stresses, such as financial hardship experienced by the adult children of older immigrants. The Korean custom of nunchi, where one’s needs are not explicitly stated but are expected to be met by others, further complicated the situation. Cultural misunderstandings and miscommunications were significant sources of conflict, especially between mothers/in-law and daughters/-in-law regarding role expectations at home. Our female participants felt that they were expected to fulfill domestic responsibilities and provide free childcare and household work.

Most participants expressed frustration and helplessness related to the growing distance between different family members that result from cultural and intergenerational differences. They also commented on the limited places to socialize outside of their homes. Older immigrants were seen as vulnerable to loss of their social capital as well as social isolation. Their ability to access support and services outside their homes was often limited. Our participants also noted they were experiencing deteriorating health, both physically and mentally, as well as reduced mobility. They rarely reported experiencing abuse because the stigma of bringing shame to the family outweighed the need to protect themselves. Those experiencing abuse were unable to access support systems due to language barriers and cultural dissonance when trying to find help.

From an intersectionality perspective, the acculturation gap, individual differences in language proficiency, education level, and income status can all shape how abusive situations are interpreted and experienced (Chang, 2016a). From an ecosystemic perspective, interpretations of abuse are influenced by individual differences and their relationship with the social, cultural, economic, and political environment (Heise, 1998). Subjective and nuanced cultural interpretations of elder abuse influences perceptions and experiences of abuse and its consequences, and what intervention strategies are perceived as acceptable, appropriate, and potentially effective. Lee and colleagues (2011) reported that older Korean immigrants in the United States perceived only physical abuse as a reportable offence, compared to older adults in Korea who viewed other types of abuse such as emotional abuse to be equally worthy of reporting to authorities.

As immigrants age, they face challenges reconciling cultural differences between their old and new countries (Kim, Kim, & Hurh, 1991). Expectations about aging can differ depending on place of origin. In Korea, elders in the family are usually treated with respect and frequently consulted on important family matters (Chung, 2016). Our participants often remarked that the younger generation was heavily influenced by “Western values” and did not know how to respect elders. Moreover, because of language barriers, many of our participants had to rely on their English-speaking children to navigate social-support systems and resources – and access to their grandchildren. This reversed the customary family hierarchy, creating unsettling cognitive dissonance for many older immigrants.

Family conflict is rarely discussed with those outside of the trusted inner circle (Lee & Eaton, 2009). This creates a sense of deep-seated resentment and indignation about elder abuse; This emotion is similar to the Korean concept of “han,” which can be defined as “an internalized feeling of deep sorrow, resentment, grief, regret, and anger” (Kim, 2019). This concept reflects complex emotions that may be related to suppressed trauma among Korean people, who have suffered from a long history of foreign invasion, oppression, and colonialism (Kim, 2017). Many of our participants felt disappointed and frustrated at not being able to seek justice while witnessing or experiencing abuse, but they often felt that sharing such trauma with service providers and authorities violated the cultural norm for how to handle these issues.

Conclusion

We identified four predominant elder abuse risk factors at micro, meso, and macro-levels: lack of knowledge of English language, financial dependence on others, social isolation, and cultural differences that intersect to increase the risk of abuse. Public health practices and policies intended to address elder abuse should consider the dynamics of intersectionality at individual, community, and societal levels. Intervention strategies must be culturally and linguistically responsive to maximize their effectiveness. Given the importance of community-based agencies such as churches, more consistent and structured support should be provided for agencies serving immigrant populations. Providing strategic and concerted support to community-based agencies will be an important step toward addressing elder abuse.

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