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老年人虐待与忽视 的全球应对: 在全球范围内建设基层医疗护理体系 处理该问题的能力:主要报告

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

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A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to Deal with the Problem Worldwide: Main Report


致谢 这份出版成果是来自世界卫生组织老龄化与生命过程项目组(WHO/ALC)与日内瓦大学跨学科 老年学中心(CIG-UNIGE)的合作研究项目“老年人虐待与忽视的全球应对:在全球范围内建立基层 医疗护理体系处理该问题的能力”。这个项目由世界卫生组织老龄化与生命过程小组协调员 Alexandre Kalache博士,以及日内瓦大学/大学医院助理教授Charles-Henri Rapin教授创立并监 督的。Karina Kaindl女士在项目监督员的指导下协调整个项目并且撰写了这份报告。 这个项目受到了世界卫生组织非传染性及慢性疾病部门和家庭与社区健康群组以及日内瓦大学 跨学科老年学中心(CIG-UNIGE)的技术与财政支持。非常感谢西班牙社会福利与劳动部(IMSERSO) 和西班牙老年病学与老年学协会(SEGG)的合作与支持,他们提供了在西班牙的研究资金和到西班牙 产生的交通费用,以及维克多利亚共同体部门的合作与支持,他们组织、实施并资助了在澳大利亚 的研究资金。 研究协调员希望热烈地感谢他们来自蒙特利尔的研究伙伴,他们提供了一套问题以及他们最初 设计和试用的社会工作评估表,这两者都在这个项目中用于测试。1 蒙特利尔小组还慷慨地提供了专 题小组研究地方计划以及他们的专业意见。特别感谢参加了参与国家的国家研究的老年人、基层医 疗护理(PHC)人员以及社会工作者。非常感谢我们的研究专家、评估员、国家协调员、专题小组促 进员以及审查员的技术贡献。2 对这项研究的完成以及这份报告的出版提供慷慨的财政支持的是日内瓦大学国际学术网络 (GIAN; http://www.ruig-gian.org)。GIAN是一个由日内瓦大学国际问题研究生院(GIIS)以及发展 问题研究生院(GIDS)创立的国际研究网络。它的主要目标是通过支持服务于和平与正义的政策相关 研究来创造不同实体——主要是学术机构和国际组织——之间的协作。

1 这个小组的研究成员包括Mark Yaffe (麦吉尔大学和圣玛丽医学中心),Maine Lithwick (雷森卡内医疗与社会服务中心)以及Christina Wolfson (麦吉尔大学和莫蒂默B.戴维斯犹太综合医院)。 2 研究专家、评估员以及国家协调员的列表可以在74页找到。


Acknowledgements This publication results from the joint research programme “A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to Deal with the Problem Worldwide� undertaken by the World Health Organization Ageing and Life Course Programme (WHO/ALC) and the Center for interdisciplinary Gerontology at the University of Geneva (CiG-UNiGE). The project was initiated and supervised by Dr Alexandre Kalache, Coordinator of the WHO Ageing and Life Course unit, and by Professor Charles-Henri Rapin, Adjunct Professor at the University of Geneva/ University Hospital of Geneva. Ms Karina Kaindl coordinated the project and wrote this report under the direction of the project supervisors. The project received technical and financial support from the Department of Noncommunicable and Chronic Diseases and the Family and Community Health Cluster of WHO and from CiG-UNiGE Gratefully acknowledged are the cooperation and support of the Ministry of Social Welfare and Labour (iMSERSO) and Spanish Society of Geriatrics and Gerontology (SEGG), which provided funding for the research in Spain and for the costs that emerged for the translation into Spanish, and of the Department for Victorian Communities, which organized, carried out and funded the research in Australia. The study coordinators wish to warmly thank their research partners from Montreal who provided the set of questions and the Social Work Evaluation Form originally devised and piloted by them, both tested within this project. The Montreal team has also generously provided the focus group research protocol used locally and their expert advice. Special thanks are due to the older people, primary health care (PHC) professionals and social workers who took part in the national studies of the participating countries. Gratefully acknowledged are the technical contributions of our research experts, evaluators, country coordinators, focus group facilitators and reviewers. The generous financial support for the completion of this study and publication of this report was provided by the Geneva international Academic Network (GiAN; http://www.ruig-gian.org) GiAN is an international research network founded by the University of Geneva, the Graduate institute of international Studies (GiiS) and the Graduate institute of Development Studies (GiDS). Its main objective is to create synergies among various entities, principally academic institutions and international organizations, through support for policy-relevant research in the service of peace and justice.


目录 前言

1

缩略语

3

执行总结

5

1 研究背景

7

1.1 什么是老年人虐待和忽视?

7

1.2 前期工作

9

1.3 老年人虐待与忽视以及基层医疗护理人员的角色

11

1.4 在基层医疗护理环境下侦测老年人虐待现象

15

2 项目

17

2.1 项目目标

17

2.2 老年人虐待嫌疑指标

19

2.3 研究设计和方法

21

3 发现与讨论

27

3.1 老年人专题小组

27

3.2 基层医疗护理人员专题小组

31

3.3 研究结果对于EASI工具的启示

37

3.4 社工研讨会

45

3.5 基层医疗护理人员与社工的研讨会

51

4 建议与结论

59

5 参考文献

65

6 项目组

67

项目协调员

67

研究合作者与专家

67

合作与试点中心/各国研究的国家协调员

67

报告评估员

68

校对

68

附录1:专题小组研究计划

69

附录2:社会工作评估表

83

附录3:PAHO手册

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Table of Content Preface

2

4

Executive summary

6

1 Research background

8

1.1 What is elder abuse and neglect?

8

1.2 Preliminary work

10

1.3 Elder abuse and neglect and the role of PHC professionals

12

1.4 Detecting elder abuse in a PHC setting

16

2 The project

Abbreviations

18

18

2.2 The Elder Abuse Suspicion Index

20

2.3 Research design and methodology

22

3 Findings and discussion

28

3.1 Focus groups with older people

28

3.2 Focus groups with PHC professionals

32

3.3 Implications of the results for the EASI tool

38

3.4 Workshop with social workers

46

3.5 Workshop with PHC professionals and social workers

52

4 Recommendations and conclusions

60

5 References

65

6 Project team

67

Project coordinators

67

Research partners and experts

67

Collaborating and piloting centres/country coordinators of the national studies

67

Report evaluators

68

Proof-reader

68

Annex 1: Focus groups research protocol

70

Annex 2: Social work evaluation form

84

Annex 3: PAHO manual

148

2.1 Aims and objectives


前言 联合国统计指出到2025年老年人 3的数量将从现在的6亿翻一倍到达12亿。每个月都有1百万 的人度过60岁生日,其中80%在发展中国家。尽管发达国家中老年人口比例更高,但是发展中国家 老年人口百分比上升的速度更快(联合国人口部门,2004)。进一步地,发展中国家的快速老龄化问 题发生在剧烈社会变化的环境下,包括城市化、女性工作参与程度上升、工业化和贫穷的蔓延。尽 管老年人虐待不算是一个新的现象,但在全世界如此深刻社会变革环境下的快速老龄化,将不可避 免地导致它的蔓延与发生率上升。 直到最近,老年人虐待,或者说对老年人的不公正对待,一直都是一个被隐藏于公众视线之外 的社会问题,通常情况下都被看成是私人问题。然而,老年人虐待实际上是随着时间不断重复的人 际间暴力的一种显现。儿童和配偶(主要是女性)虐待最初显现并且都被视为家庭暴力问题。直到二十 世纪晚期,研究证实了儿童虐待和对妇女施暴的广泛性,它们才得到了公众的明显注意。结果,人 际间暴力从此只通过年龄进行划分。和其他的试图解释不同人群受害性的变量不同,老龄化会引起 遭受虐待的额外风险,缘于对他人依赖程度的上升、社会孤立以及伴随而来的身心脆弱。而且,老 年人来自那样一个避免在公开场合讨论私人问题的年代。因此,谈论老年人虐待继续成为一种禁 忌,在全世界大多数社会中被低估和忽视了。 虽然如此,关于老年人虐待——包括普遍的忽视问题——的证据随着时间在积累,在各个发展 中国家和发达国家中表现出它是一个重要的公共医疗和社会问题。为此,需要在全球范围有一个精 心协调安排的应对措施。从社会医疗的的角度来看,除非基层医疗护理设施(PHC)和社会服务部门 做出充分准备来鉴别和处理老年人虐待问题,否则它将继续被低估和忽视。 世界卫生组织老龄化与生命过程项目组(WHO/ALC)和日内瓦大学跨学科老年学中心(CIGUNIGE),以及来自各个大洲的合作者,执行了这次研究,目的是在基层医疗护理设施环境下发展出 一套预防老年人虐待的方案。这项研究包括一个有八个国家参与的定性研究项目,集中测试最初由 蒙特利尔的研究者们设计的问题。设计这些问题的目的是提高基层医疗护理专业人员对老年人虐待 问题的了解。

3 在整篇文章中老年人被一般定义为65岁及以上的人,但在这里老年人指60岁及以上的人。

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Preface United Nations estimates indicate that by 2025 the number of older people3 will double from the current 600 million to 1.2 billion. Of the one million people who reach their sixtieth birthday each month, 80% are in the developing world. Although the proportion of older people out of the total population is higher in developed countries, the percentage increase of the elderly population is much greater in the developing world (UN Population Division, 2004). Furthermore, rapid ageing in developing countries is taking place in the context of fast social change, such as urbanization, increased participation of women in the workplace, industrialization and prevailing poverty. Although elder abuse is not a new phenomenon, the speed of population ageing worldwide, in the context of such profound societal changes, inevitably will lead to an increase in its incidence and prevalence. Until very recently, elder abuse, the mistreatment of older people, was a social problem hidden from public view and mostly regarded as a private matter. However, elder abuse is a manifestation of the timeless phenomenon of interpersonal violence. Child and partner (mainly female) abuse were the first to emerge and were both seen as mostly family (domestic) violence issues. Public awareness towards child abuse and violence against women gained prominence only once studies in the last quarter of the twentieth century provided evidence of their magnitude. As a consequence, interpersonal violence was then framed only within age-specific compartments. Apart from other parameters that try to explain victimization in different population groups, ageing may trigger an additional risk of abuse due to the increased dependence on others, social isolation and frailty that accompany it. Moreover, older men and women come from generations that avoided discussing private issues. As a result, elder abuse continues to be a taboo, mostly underestimated and ignored by societies across the world. Evidence is accumulating, however, to indicate that elder abuse, which includes the pervasive issue of neglect, is an important public health and societal problem that manifests itself in both developing and developed countries. As such, it demands a global orchestrated response. From a health and social perspective, unless the primary health care (PHC) and social services sectors are well equipped to identify and deal with the problem, elder abuse will continue to be underdiagnosed and overlooked. WHO/ALC and CIG-UNIGE, with partners from all continents, conducted this study in order to develop a strategy to prevent elder abuse within the PHC context. The study consisted of a qualitative research project in eight participating countries focused on testing questions originally devised by researchers in Montreal. These questions were aimed at raising awareness among PHC professionals of the issue of elder abuse.

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缩略语 ALC

老龄化与生命过程项目组/世界卫生组织

CIG

跨学科老年学中心

CSSS

医疗与社会服务中心

EASI

老年人虐待嫌疑指标

GIAN

日内瓦国际学术网络

GIDS

发展问题研究院

GIIS

国际问题研究院

HAI

国际帮助老人组织

HUG

日内瓦大学医院

IMSERSO

社会福利与劳动部(西班牙)

INPEA

国际老年人虐待预防网络

MIPAA

马德里国际应对老龄化计划

NGO

非政府组织

PAHO

泛美医疗组织

PHC

基层医疗护理

Poliger

日内瓦大学医院老年病门诊部

SEGG

西班牙老年病学与老年学协会

SWEF

社会工作评估表

UNIGE

日内瓦大学

WHO

世界卫生组织

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Abbreviations ALC

Ageing and Life Course Programme/World Health Organization

CIG

Center for Interdisciplinary Gerontology

CSSS

Centre de Santé et de Services Sociaux

EASI

Elder Abuse Suspicion Index

GIAN

Geneva International Academic Network

GIDS

Graduate Institute of Development Studies

GIIS

Graduate Institute of International Studies

HAI

HelpAge International

HUG

Hôpitaux Universitaires de Genève (University Hospital of Geneva)

IMSERSO

Ministry of Social Welfare and Labour (Spain)

INPEA

International Network for the Prevention of Elder Abuse

MIPAA

Madrid International Plan of Action on Ageing

NGO

nongovernmental organization

PAHO

Pan-American Health Organization

PHC

primary health care

Poliger

Policlinique de Gériatrie des Hôpitaux Universitaires de Genève (Geriatric Policlinic of the University Hospital of Geneva)

SEGG

Spanish Society of Geriatrics and Gerontology

SWEF

Social Work Evaluation Form

UNIGE

University of Geneva

WHO

World Health Organization

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执行总结 世界卫生组织(WHO)和日内瓦大学跨学科老年学中心(CIG/UNIGE),联合八个国家的机构(澳 大利亚、巴西、智利、哥斯达黎加、肯尼亚、新加坡、西班牙和瑞士),组织了一次联合研究,目的 是对付一个重要但仍被隐藏的社会问题:老年人虐待与忽视。这项研究的基础来自一个蒙特利尔的 跨院校多学科小组所作的开拓性工作。 研究项目的目的包括:

・发展并启用一套可靠的工具,可以应用在不同的地理和文化环境下,用于促进基层医疗护理专 业人员对于老年人虐待和忽视问题的了解。

・为了预防策略的发展,通过实例教学建设基层医疗护理人员处理老年人虐待与忽视问题的能力。 最初的研究计划当中包括了发展并启用一套通用的例行筛查工具,帮助侦测基层医疗护理专业 人员中的老年人虐待与忽视行为。然而,在最初阶段咨询了专家和顾问的意见后,发现在基层医疗 护理领域应用老年人虐待筛查工具的危险性;老年人虐待不只涉及到病人,也涉及到基层医疗护理 人员的社会心理压力,他们目前也不具备处理好这些问题的策略。最终考虑下来,发展一套提高基 层医疗护理人员对老年人虐待问题了解的工具,使得他们谨慎处理可能的虐待事件是更合适的。因 此,这项WHO-CIG研究的目标是提供一个工具来侦测老年人虐待的嫌疑迹象,以老年人虐待嫌疑指 标(EASI)为模板,这是之前在蒙特利尔开发并测试的一套问卷。 老年人虐待以及对它的侦测是一项富有挑战性和高度敏感的问题,需要不同语言上和文化上具 体的方法和词汇。所以,要创造一个通用的工具意味着在全球的测试。第一步就是在前面提到的八 个参与国家中对一套问卷,也就是蒙特利尔老年人虐待嫌疑指标,做定性测试。进一步的行动比如 在临床环境试用工具以及扩大参与国家的范围,将会是未来研究的基础。 这项研究的结果显示,在参与研究的老年人与基层医疗护理人员,尤其是后者的意见中,提供 一个涵盖老年人虐待的关键问题的简短指导意见可能是预防和侦测这类虐待的重要环节。然而,一 个适用于所有文化和地理环境的通用的指导意见还没有开发出来;它的内容和用词的合适性因环境 而不同。尽管如此,研究参与者认为,为基层医疗护理人员准备一套问卷是提高他们对老年人虐待 了解的一个必要的起点。

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1 Executive summary The World Health Organization (WHO) and the Center for Interdisciplinary Gerontology/University of Geneva (CIG/ UNIGE), in association with institutions in eight countries (Australia, Brazil, Chile, Costa Rica, Kenya, Singapore, Spain and Switzerland), formed a joint research programme aimed at tackling a substantial and yet hidden social problem: elder abuse and neglect. The foundations of the study were provided by the ground-breaking work conducted by a multidisciplinary and inter- institutional team from Montreal. The project objectives are: •

To develop and validate a reliable instrument applicable in different geographical and cultural contexts in order to increase awareness among PHC professionals to the problem of elder abuse and neglect.

To build the capacity of PHC workers to deal with elder abuse and neglect through evidencebased education for the development of prevention strategies.

The original project outline comprised the development and validation of a universal routine screening tool to facilitate the detection of elder abuse and neglect among PHC professionals. Consultations with experts and advisers during the initiation phase of the project, however, have indicated that it is critical to apply the concept of an elder abuse screening tool in the field of PHC; elder abuse involves psychosocial moments of stress not only for the patients but also for the PHC professionals, who are currently not equipped well enough with follow-up strategies. It was considered more appropriate to ultimately develop a tool that helps raise awareness about the issue of elder mistreatment among the PHC professionals and sensitizes them in dealing with potential abuse cases. Therefore, the goal of the WHO-CIG study is to provide an instrument to detect suspicions of elder abuse modelled on the Elder Abuse Suspicion Index (EASI), a questionnaire previously developed and tested in Montreal. Elder abuse and its detection are challenging and highly sensitive issues that need a linguistically and culturally specified approach and vocabulary. Consequently, the creation of a “universal” tool implies global testing. The first step was the qualitative testing of a set of questions, which led to the Montreal EASI, in the eight participating countries mentioned above. Further action such as the piloting of the tool in clinical settings and the expansion of the range of participating countries will be the basis for future studies. The results of the study confirm that in the opinion of the older people involved and, in particular, of the PHC professionals, the provision of a short instrument covering key dimensions of elder abuse might be a critical step in preventing and detecting such abuse. According to such results, however, a universal instrument applicable to all cultural and geographical contexts has not yet been developed; the appropriateness of its content and wording vary, depending on the setting Nevertheless, the study participants believe that it is essential to equip PHC professionals with a set of questions to serve as a starting point in raising awareness about elder abuse. 6


1 研究背景 1.1 什么是老年人虐待和忽视? WHO-CIG项目组采用了1995年由老年人虐待应对措施(Action on Elder Abuse)(英国)4 提出 的定义: “在本应充满信任的关系中,发生的一次或者多次致使老年人受到伤害或者处境困难的行为, 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。” 老年人虐待对老人的健康和幸福有着严重的影响并且会表现为多种形式:身体上的、语言上 的、心理上/情感上的、性生理上的和财产上的。它也可能简单地呈现为故意的或者无意的忽视。虐 待和忽视是文化上区分定义的现象,反映了价值观、行为准则和无法认同的人际行为间的差异。 和其他形式的虐待一样,老年人虐待是一种对人权的侵犯,并且是造成伤害、疾病、生产力下 降、孤立和绝望的重要原因。研究“被忽视的声音:从老年人的角度来看老年人虐待问题”(WHO/ INPEA,2002a)指出老年人将虐待理解为以下三个大的领域:忽视(孤立、遗弃和社会排斥),侵犯 (人权、法律权利和医疗权利)以及剥夺(选择、决定权、身份、财产和尊敬)。 现代化、工业化、老龄化的人口、城市化和日趋增长的女性劳动力或许可以解释老年人虐待报 告的增多。流行率/估算仅仅存在于指定的国家,迄今为止也就限制在一些发达国家内。在已有的老 年人虐待流行率研究中,根据定义、调查方法和抽样方法的不同,流行率从1%到35%不等 (Pillemer & Finkelhor, 1988; Ruiz Sanmartín et al , 2001;Yan & Tang, 2001)。然而这些数 据可能只是代表了冰山一角,一些专家认为老年人虐待的漏报率有80%之多。估计老年人虐待事件 的报告率为1/15到1/6。造成如此低报告率的原因可能是对老年人的孤立、缺乏统一的报告法规以 及人们——包括专业人员——对报告可疑的老年人虐待与忽视事件的普遍的抵制情绪。在发展中国 家,尽管没有相关的系统的统计数据收集或者流行率研究,犯罪和社会福利记录、新闻报道和小范 围研究也提供了证据表明对老年人的虐待、忽视和财产剥削是很普遍的。

4 可参见 http://www.elderabuse.org.uk/Mainpages/Questions.htm

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1 Research background 1.1 What is elder abuse and neglect? The WHO-CIG adopted the definition developed by Action on Elder Abuse (UK) in 1995: “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.” Elder abuse has serious consequences for the health and well-being of older people and can be of various forms: physical, verbal, psychological/emotional, sexual and financial It can also simply reflect intentional or unintentional neglect. Abuse and neglect are culturally defined phenomena that reflect distinctions between values, standards and unacceptable interpersonal behaviours. Like any other form of abuse, elder abuse is a violation of human rights and a significant cause of injury, illness, lost productivity, isolation and despair. The study “Missing voices: views of older persons on elder abuse” (WHO/INPEA, 2002a) indicated that older people perceive abuse under three broad areas: neglect (isolation, abandonment and social exclusion), violation (of human, legal and medical rights) and deprivation (of choices, decisions, status, finances and respect). Modernization, industrialization, an ageing population, urbanization and an increase in the number of women in the workforce may explain increased reports of elder abuse. Prevalence rates/estimates exist only in selected countries and have so far generally been restricted to a few developed nations. Where there are prevalence studies on elder abuse, rates range between 1% and 35% (Pillemer & Finkelhor, 1988; Ruiz Sanmartín et al , 2001; Yan & Tang, 2001), depending on definitions and survey and sample methods. These figures, however, may represent only the tip of the iceberg, and some experts believe that elder abuse is underreported by as much as 80% Estimates of the number of elder abuse cases reported range from 1 in 15 cases to 1 in 6 cases. These low rates may be due to the isolation of older people, the lack of uniform reporting laws and the general resistance of people – including professionals – to report suspected cases of elder abuse and neglect. In developing countries, although there is no systematic collection of statistics or prevalence studies, crime and social welfare records, journalistic reports and small-scale studies provide evidence that abuse, neglect and financial exploitation of older people appear to be widely prevalent.

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1.2 前期工作 这次WHO-CIG联合项目响应了马德里国际应对老龄化计划(MIPAA)(联合国,2002)的建议, MIPAA是于2002年四月在马德里举办的世界老龄化问题大会的主要成果。MIPAA建立在联合国 大会1991年采纳的联合国对待老年人准则的基础上,口号是“让生命的延续成为生活的延续”, 它浓缩了通向一个对所有年龄而言的公平社会需要作出的努力。MIPAA有几点提到了老年人虐待 问题。它呼吁各个阶层各个部门的态度、政策以及行为有所改变,确保每个地方的人都能有安全 感、有尊严地变老,并且享有公民的一切权利。同时,MIPAA也意识到了老年人虐待问题的一般 性。尽管MIPAA指出老化过程使得身体痊愈能力下降,伤口的危害也会因为老人羞愧和恐惧可能 导致的不愿寻求帮助而恶化,它也强调了老年人虐待通常不只是身体虐待的形式。鉴于此, MIPAA设立了目标,要消灭一切形式的对老年人的忽视、虐待和暴力,并且创造援助性服务来解 决老年人虐待问题。 MIPAA描绘了三个重点的方向:老年人与发展;提高老年的健康程度和幸福感;确保使之可行 的支持的环境。每一个方向都在全球对抗老年人虐待需要付出的努力中有重要的意义。更具体地来 说,MIPAA强烈建议把重点放在通过多部门、跨职能的以社区为平台的方法来预防和管理老年人虐 待问题,以消灭一切形式的忽视、虐待与暴力。此外,MIPAA认为在全球都有非常紧迫的需要去为 所有与老年人接触的医疗护理人员扩展在老年病学与老年学领域的受教育机会,以及为社会服务部 门的专业人员扩展关于老年保健的教育项目。非正式的护理者也需要有途径来接受照料老人的信息 和基本训练。与此同时,要鼓励医疗和社会服务专业人员报告可疑的老年人虐待事件,并且要求他 们把所能提供的保护和援助手段告知那些被怀疑遭到虐待的老年人。

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1.2 Preliminary work The WHO-CIG joint programme responds to the recommendations of the Madrid International Plan of Action on Ageing (MIPAA) (UN, 2002), the principal outcome of the World Assembly on Ageing, which took place in Madrid, April 2002. The MIPAA is based on the United Nations Principles for Older Persons adopted in 1991 by the United Nations General Assembly under the slogan “To add life to the years that have been added to life�, which encapsulates the needed effort towards a just society for all ages. The MIPAA has several implications that address the issue of elder abuse. It calls for changes in attitudes, policies and practices at all levels and in all sectors in order to ensure that people everywhere are able to age with security and dignity, as citizens with full rights. Furthermore, the MIPAA recognizes the universality of the problem of elder abuse. Although the MIPAA points out that the process of ageing brings with it a declining ability to heal and that the impact of trauma may be worsened because shame and fear may result in reluctance to seek help, it also emphasizes that elder abuse is often not solely of a physical form. In this respect, the MIPAA sets out as objectives the elimination of all forms of neglect, abuse and violence directed at older people and the creation of supporting services that address elder abuse. The MIPAA delineates three priority directions: older people and development; advancing health and well-being into old age; and ensuring enabling and supportive environments. Each of these directions has major implications in the needed global effort to fight elder abuse. More specifically, the MIPAA strongly recommended more emphasis on the prevention and management of elder abuse through the adoption of multi-sectorial, interdisciplinary community-based approaches to eliminate all forms of neglect, abuse and violence. Furthermore, the MIPAA states that there is an urgent need worldwide to expand educational opportunities in the field of geriatrics and gerontology for all health professionals who work with older people and to expand educational programmes on older people’s health for professionals in the social services sector. Informal caregivers also need access to information and basic training on the care of older people. This goes together with the encouragement of health and social services professionals to report suspected elder abuse as well as with the demand on health and social services professionals to inform older people suspected of suffering abuse about the protection and support that can be offered.

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世界卫生组织已经意识到需要建立全球战略来预防老年人虐待。世界卫生组织老龄化与生命过 程项目组(ALC)从2000年早期就开始从事在老年人虐待领域的工作。在2002年,由ALC指导并与 国际老年人虐待预防网络(INPEA)、国际帮助老人组织(HAI)以及一些国家的学术机构和代表草根团 体的非政府组织(NGOs)共同合作的历史过去两年的多中心研究项目的成果发表了。该研究集中关注 了老年人自身以及基层医疗护理人员对于老年人虐待问题的理解和观点,通过在八个国家(阿根廷、 奥地利、巴西、加拿大、印度、肯尼亚、黎巴嫩和瑞典)设立的专题小组。成果出版物“被忽视的声 音:从老年人的角度来看老年人虐待问题”(WHO/INPEA, 2002a)被看作是该领域的一个里程碑并 且引领了后续研究的开展。在2002年11月,WHO与INPEA和学术合作者一起,在安大略老年人虐 待会议上发表了“多伦多全球预防老年人虐待宣言”(WHO/INPEA, 2002b)。这项宣言呼吁全世界 针对预防老年人虐待做出行动。 几年来,日内瓦大学跨学科老年学中心(CIG-UNIGE)和日内瓦大学医院老年病门诊部 (POLIGER-HUG)已经从事了关于老年人虐待的重要研究,例如开发筛查工具以及开发面向社会与 医疗服务人员的培训课程。这项开创性的工作已经在与自由老年因特网(RIFVEL; http://www.fep umontreal.ca/violence/)的合作下开展,目的是在法语共同体之间以及地方草根组织的紧密关系中 交流信息。接着,在2004年,POLIGER联合CIG以及许多其他学术机构一起举办了国际学术讨论 会热浪(HEATWAVE) 2004。不同领域的专家讨论和展示了他们对于老年人虐待问题的见解、诠释 和建议,目的是从2003年夏天欧洲大约40000老人死于忽视与不当护理的事件中吸取教训,得出 一个简要的行动方案以应对将来的热浪。 现存的公共卫生、社会、医疗和法律活动及系统之间的合作有待加强,因为它们目前还只是依 赖自身来预防、侦测和减少老年人虐待。对此,在2004年1月,WHO-CIG项目“老年人虐待与忽 视的全球应对:在全球范围内建设基层医疗护理体系处理该问题的能力”启动了。

1.3 老年人虐待与忽视以及基层医疗护理人员的角色 自从1975年(Baker, 1975)“打老人”这个术语出现以来,医生普遍对老年人虐待与忽视问题 的反应进展迟缓。对该领域的研究的缺乏和基层医疗护理人员对它有限的认知相匹配。评估青少 年、青年和女性间人际暴力的研究比关于老年人虐待和忽视的研究的进展快得多,尽管这个问题更 早以前就被认为需要关注。不过观点正在改变,这从许多国家的研究结果中反映出来5 。老年人虐待 开始逐渐被认为是一种严重的社会和(公共)医疗问题。老年人虐待的发生频率和严重程度很可能在未 来数十年间随着人口整体年龄的增长、看护责任和关系的转变以及需要长期照料的老年人数量的上 升而明显增大。

5 举例来说,PubMed在2006年2月收到1111次对“老年人虐待”的点击。

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WHO has recognized the need to establish a global strategy for the prevention of the mistreatment of older people. The WHO Ageing and Life Course Programme (ALC) has been working in the field of elder abuse since early 2000. In 2002 the results of a multicentric study conducted by ALC in collaboration with the International Network for the Prevention of Elder Abuse (INPEA), HelpAge International (HAI) and partners from academic institutions in a range of countries as well as nongovernmental organizations (NGOs) representing grass-roots organizations over the previous two years were published. The study focused on the views and perceptions of older people and PHC workers of elder abuse through focus groups held in eight countries (Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden). The resulting publication “Missing voices: views of older persons on elder abuse” (WHO/ INPEA, 2002a) was considered a milestone in the field and has led to the development of further research. In November 2002, WHO, together with INPEA and academic partners, launched “The Toronto declaration for the global prevention of elder abuse” (WHO/INPEA, 2002b) at the Ontario Elder Abuse Conference. This declaration is a call for action aimed at preventing elder abuse worldwide. Over the years, the Center for Interdisciplinary Gerontology at the University of Geneva (CIGUNIGE) and the Policlinique de Gériatrie des Hôpitaux Universitaires de Genève (POLIGERHUG) have undertaken important research on elder abuse, such as the development of screening tools and training courses for social and health workers. This seminal work has been conducted in partnership with the Internet network Vieillir en Liberté (RIFVEL; http://www.fep.umontreal.ca/ violence/) for the exchange of information among French-speaking communities and in close relationship with local grass- roots organizations. Moreover, in 2004, POLIGER organized in collaboration with CIG and a variety of other institutions the international colloquium HEATWAVE 2004 Specialists from various domains discussed and presented their perspectives, interpretations and advice on elder abuse, with the purpose of coming up with a simple plan of action for future heatwaves in order to draw a lesson from summer 2003, when approximately 40 000 older people died in Europe due to neglect and inappropriate care. The cooperation between existing public health, social, medical and legal activities and systems needs to be improved, as they depend on each other for the prevention, detection and reduction of elder abuse. As a response, in January 2004, the WHO-CIG project “A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to Deal with the Problem Worldwide” was initiated.

1.3 Elder abuse and neglect and the role of PHC professionals Since the appearance of the term “granny battering” in 1975 (Baker, 1975), physicians have generally been slow to react towards the issue of elder abuse and neglect. The paucity of research in this area has been matched by limited awareness among PHC professionals. Research on assessing interpersonal violence in adolescents, young adults and women is far more advanced than that on elder abuse and neglect, which are recognized as problems in need of attention over a longer period of time. Perceptions are changing, reflecting results from studies in many countries. Elder abuse is starting to be recognized as a serious social and (public) health issue. The occurrence and severity 12


美国国家科学研究委员会(美国国家科学研究委员会,2003)意识到,为了改进和发展在一系列 临床环境下筛查老年人虐待现象的新方法,需要大量的实质性研究。另外,它还强烈建议去系统地 研究报告行为及其效果。 尽管一个全面的医疗护理体系是在社区层面协作下介入家庭暴力的关键,但是诊所医生仅仅报 告了所有老年人虐待报告案例的2%,相比于家庭成员的报告(20%)、医院的报告(17.3%)与家庭医 疗援助的报告(9.6%)(Rosenblatt et al., 1996)。即使侦测老年人虐待现象提上了一些医院的议程, 仍然只有一小部分医院有合适的规章制度和相关的指导方针来处理这类问题(Ahmad & Lachs, 2002; Lachs, 2004)。 理解日趋增长和愈发精细的医疗与社会监督机制及审查实践的本质和价值,以及它们对于依地 理区域划分的老年人虐待率的影响,是一个核心问题。毫无疑问,医疗护理环境至关重要。比如 说,在美国每年有接近85%的65岁及以上老人使用了正式的流动护理服务,并有16-20%的老人住 过院(美国国家科学研究委员会,2003)。因此,医生需要在侦测老年人虐待方面,有能力识别风险 因素以及应用特殊的诊断技术。然而许多医生以及其他基层医疗护理人员还并不熟悉老年人虐待的 定义、诱发因素、诊断以及干预策略,因为通常它并不是一个可以快速做出判断的问题。尽管如 此,急诊室、简易诊所和家庭医生还是老年人虐待的受害者们普遍的就医手段。类似地,尽管忙碌 的基层护理办公室不是一个能做长时间身体检查的理想场所,它依然可能是受害者期望被发现和保 护的唯一希望。在以上所有这些环境下,有机会接触到潜在的受害者的医生都有必要掌握良好的评 估手段。 医疗行业现在才刚刚开始将注意力放在对老年人虐待的研究、侦测和预防上面。医生处在一个 独一无二的可以第一时间侦测老年人虐待与忽视的位置,他们因此也背负了特别的责任去促进自身 更了解并更有效地干预虐待问题。不过也不能仅靠医生去独自处理老年人虐待问题。现存的公共卫 生、社会、医疗、法律行为和系统之间的合作需要好加强,它们互相之间都需要依赖其他部分的支 持来完成对虐待的侦测、评估技术以及减少虐待发生率。这显得尤其真实,当大部分老年人虐待事 件都发生在脆弱的老人身上,而且这些老人都是那些很少有机会,或者因为社会孤立而难以接触到 家庭调查的老人。医疗场所中的门诊咨询有时可能是老年人在家庭之外唯一的常规互动方式。

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of elder mistreatment are likely to increase markedly over the coming decades, as the population ages, as caregiving responsibilities and relation- ships change and as increasing numbers of older people require long-term care. The United States National Research Council (National Research Council, 2003) recognized that substantial research is needed in order to improve and develop new methods of screening for possible elder mistreatment in a range of clinical settings. Moreover, it strongly recommends systematic studies of reporting practices and the effects of reporting. Although a comprehensive health-care response is the key to a coordinated community-wide approach to family violence, physicians report only 2% of all reported cases of elder abuse, compared with reports from family members (20%), hospitals (17 3%) and home health aids (9 6%) (Rosenblatt et al , 1996). Even though the detection of elder abuse is an issue in some hospitals, only a few hospitals have appropriate protocols and follow-up guidelines for dealing with the problem (Ahmad & Lachs, 2002; Lachs, 2004) . It is central to understand the nature and value of increased and more refined medical and social surveillance and screening practices and their effect on geographically based elder mistreatment rates. There is no doubt that health-care settings are particularly important. For instance, in the United States, each year approximately 85% of people aged 65 years and older use formal ambulatory care services and 16–20% are hospitalized (National Research Council, 2003) Therefore, physicians need to be able to recognize risk factors and to apply the diagnostic techniques specifically involved in the detection of elder abuse. Many physicians and other PHC professionals, however, are not yet familiar with the definitions, epidemiology, diagnosis and intervention strategies associated with elder abuse, since it is usually not a problem that can be assessed quickly. Nevertheless, emergency rooms, walk-in clinics and family doctors’ practices are commonly used by victims of elder abuse. Similarly, the busy primary care office, although hardly the ideal setting for a time-consuming examination, may be the victim’s only hope of detection and protection. In each of these settings, an understanding of good assessment practices is necessary for the physician in touch with the potential victim. The medical profession is only now beginning to turn its attention to research, detection and prevention of elder abuse. Since physicians are in a unique position to detect elder abuse and neglect first- hand, they have a special responsibility to promote greater awareness and effective interventions for this problem. Physicians cannot tackle elder abuse alone, however. The cooperation between existing public health, social, medical and legal activities and systems needs to be improved, as each depends on the others for detection, for assessment techniques and for the reduction of the occurrence of mistreatment This is particularly true since a substantial proportion of elder mistreatment episodes appear to occur in frail elder people, who are often least likely to participate in household surveys and who may be difficult to reach due to social isolation. Consultation at the medical practice is sometimes the only regular interaction that older people have outside their home.

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1.4 在基层医疗护理环境下侦测老年人虐待现象 老年人虐待的许多方面使得它在理想情况下容易被传统公共医疗手段筛查出来:它很流行、它 导致病态和死亡、习惯上它通常会隐藏在问诊过程中。但是与其他的疾病和情况相比,筛查老年人 虐待还是有问题的,因为一些病人可能并不希望自己被诊断为一个可能的虐待受害者。同时它也不 像筛查其他情况和疾病的血检或者其他一致准则一样有明确定义的“阳性”。 一些用于筛查和侦测老年人虐待的工具已经被开发并测试。但它们很难有效地适用于更广的范 围。有效工具的多样性表明有必要通过合作研究开发一种可以适用于不同地理和文化环境的简单可 靠的工具。这将帮助我们充分理解这个问题的多个维度。 筛查工具可能会有一些局限性。例如,一些工具只为研究目的而开发,一些工具在临床环境效 果不佳,一些工具的敏感性和具体性不强,一些工具太长、用词不当或者为家用而设计导致没有医 生使用。因此对一个侦测工具的要求很高:它要实用,容易迅速管理,对不同环境有合适清晰的用 词,并且有高度的敏感性。 仅仅有筛查工具是不够的。专业人员为了能有效地使用这些工具,他们需要了解老年人虐待问 题及其后果,并且有策略方法去干预个人行为达到良好的结果。医生要侦测老年人虐待需要克服的 困难有以下一些,他们缺少对该问题的了解,缺乏辨别和跟进一个潜在虐待案例的知识,面临伦理 问题,时间不够,还可能遇到受害者不愿报告情况。因此不只要提高基层医疗护理人员对该问题的 了解,关键的是还要让他们接受足够的训练、掌握干预策略,使他们能够在面对一位有遭受虐待和 忽视风险的老人时能做出合适的反应。不过首先,他们需要有足够的自信来克服那些阻止他们侦测 和干预的现实的障碍。

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1.4 Detecting elder abuse in a PHC setting Many aspects of elder abuse would appear to make it a condition ideally amenable to traditional public health screening: it is prevalent, it causes morbidity and mortality, and traditionally it would appear that it is often hidden during consultation. But compared with other diseases and conditions, screening for elder abuse is problematic, since some patients are probably not eager to be detected as a potential victim of abuse. Also “true positives” are not well defined by blood tests or consensus criteria used to screen for other conditions and diseases. Several screening and detection tools for elder abuse have been developed and tested. They have rarely been validated properly for wider use, however. The multiplicity of the tools available reveals the need to develop, through collaborative research, a reliable and simple tool that can be adapted and used in different geographical and cultural settings This will help to maximize the full understanding and multiple dimensions of the problem. Screening tools may have several limitations For instance, some tools are developed only for research purposes, some have low efficiency in clinical settings, the sensitivity and specificity rates of some are not addressed fully, and physicians do not use some because they are too long, their vocabulary is inappropriate or they are designed for home use. The requirements for a detection tool are thus high: It should be practical, be easy and quick to administer, have appropriate and clear wording suitable for different contexts, and show a high sensitivity rate. Screening tools by themselves are not enough, however. For professionals to be able to use the tools effectively, they need to be aware of the problem and its consequences and to have access to strategies to intervene and achieve positive outcomes for individuals. Among the obstacles physicians must overcome in order to detect elder abuse are a lack of awareness of the problem, insufficient knowledge about how to identify or follow up a potential case of abuse, ethical issues, time constraints, and the victim’s possible reluctance to report to physicians. It is crucial, therefore, not only to raise PHC professionals’ awareness but also to equip them with sufficient training and intervention strategies enabling them to react appropriately when a person is at risk of being abused or neglected. Above all, they need the confidence to overcome the very real barriers that prevent detection and intervention.

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2 项目 2.1 项目目标 建立在“被忽视的声音”研究所概述的建议策略的基础上,这次WHO-CIG项目的目标是: 开发一套行之有效的可靠的工具用于不同的地理和文化环境,作用是提高基层医疗护理人员对 于老年人虐待与忽视问题的了解。 通过案例教学培养基层医疗护理人员处理老年人虐待与忽视问题的能力,以此发展预防策略。 随着项目的开始,在2004年1月,项目协调员以及所属组织的科学领导委员会和成员举办了一 次会议。会议上对研究作出了以下建议: 尽管老年人虐待是一种在不同地理和社会经济环境下都具有相似形式的普遍的现象,合适的应 对方法还是有区别,依赖于地方信仰和价值观、资源获取能力以及法律框架等具体情况。然而,虽 然虐待的根源因社会不同而可能有巨大差异,文化规范不应当成为虐待发生或者被忽视的借口。 当试验一种工具来侦测潜在的虐待案件时,建立基本的反应机制很重要,否则许多基层医疗护 理人员将仍然不愿意处理这类问题。除此之外,在已有的模型上建立的针对老年人虐待的侦测、预 防和管理的标准化的培训模块需要进一步发展。 不存在“完美的”工具。根据个人的专业背景的不同,故事性的方法或者科学证据性的方法中 的某一个会更受欢迎。需要在工具的科学有效性和简易性方面寻找平衡,以适合各式各样的基层医 疗护理人员使用,并且让老年人也容易理解。简易性是确保基层医疗护理人员愿意使用这种工具的 关键。一个有用的对照是酒精依赖的筛查方法(例如,带有4个问题的CAGE工具; Ewing, 1984)。 最终的目的是提高医疗人员对于老年人虐待和它发生可能性的了解和敏感度。 全科医疗中心和基层医疗护理中心似乎是这次研究计划中侦测老年人虐待最好的地点。在基层 医疗护理人员当中,医生处在侦测虐待的最佳位置,因为他们往往是老人们最先寻求帮助的人。困 难在于会给医生原本就紧张的日程又增加了负担。护士可能是很好的替代,某些环境下他们常常和 病人有日常的接触。 因此,最好的选择被认为是采用已经被开发和测试的EASI(老年人虐待嫌疑指标),并在八个参 与国家中运用专题小组讨论的方式调整它的文化和语言要素。

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2 The project 2.1 Aims and objectives Based on the recommended strategies outlined in the “Missing voices” study, the WHO-CIG programme objectives were: •

To develop and validate a reliable instrument applicable in different geo- graphical and cultural contexts in order to increase awareness among the PHC professionals to the problem of elder abuse and neglect.

To build the capacity of PHC workers to deal with elder abuse and neglect through evidence based education for the development of prevention strategies.

Following the initiation of the project in January 2004, a meeting was held between the project coordinators, the scientific steering committee and members from affiliated organizations. The following recommendations for the study were made: Although elder abuse is a universal phenomenon that appears in similar forms regardless of its geographical and socioeconomic context, the appropriate responses may vary, depending for instance on local beliefs and values, availability of resources and legal frameworks. However, although the roots of abuse may be very different between societies, cultural norms should not be used as an excuse for mistreatment to occur or to be ignored When testing an instrument to detect potential abuse cases, it is crucial to establish basic response mechanisms, otherwise many PHC professionals will remain reluctant to deal with the issue. In addition, standardized training modules that focus on the detection, prevention and management of elder abuse, taking into consideration already existing models, need to be developed. The “perfect” tool does not exist. Depending on a person’s professional background, either an anecdotal or an evidence-based approach is preferred. A balance needs to be found between a scientifically validated and simple tool that is suitable for use by a wide range of PHC professionals and that is also comprehensible by older people. Simplicity is the key to success in ensuring that a tool would be used by PHC professionals. A useful comparison was made to screening for alcohol dependence (e.g. the CAGE8 tool with four questions; Ewing, 1984). The ultimate goal should be to sensitize medical professionals and raise their awareness about elder abuse and the possibility that it can occur. General practices and PHC centres seem to be the best locations for the detection of elder abuse within this research proposal. Among PHC professionals, physicians are in the best position to detect abuse, since they are often the first port of call for older people. The difficulty arises from placing another burden on the physician’s already full agenda. Nurses may be a valuable alternative, since they often have, depending on the setting, regular contact with patients. Thus, it was decided that the best option would be to adopt the EASI that had been developed and tested in Canada using focus group discussions to adjust it for cultural and linguistic factors in the eight participating countries. 18


2.2 老年人虐待嫌疑指标 EASI这项工具在蒙特利尔开发测试,研究组成员来自麦吉尔大学、圣玛丽医学中心、雷内卡森 医疗与社会服务中心以及莫蒂默B・戴维斯犹太综合医院,由加拿大医学研究所资助。EASI包含了 一些版权所有的、简短直接的问题(五个给病人的问题和一个给医生的问题),在所有办公室中医生与 病人问诊的过程中使用,并以医生熟悉的语言构成。它很容易被应用于认知正常的老年人(65岁及以 上的人)。EASI设计初衷并不是为了侦测案例,而是提高医生对老年人虐待发生的怀疑以便于合理地 转送给社区处理老年人虐待方面的专家,比如社工。第二个目的是帮助家庭医生在不断重复使用这 一系列简单问题的同时熟悉老年人虐待问题。尽管EASI不能保证侦测到老年人虐待,但它的使用表 示医生已经了解到老年人虐待问题,并且可以因此将可能的案例提交给社会与社区服务部门。 EASI问题和应用的风格紧跟相关文献中可以找到的建议。使用明确的、关于具体行为的封闭式 问题,上下文定向的前言式的表述,并且同时评估陌生人的攻击性行为以及家庭成员/看护者的虐 待,是适合于老人的。此外,亲身访谈有以下一些好处:借此可以直观地看到被访者的身体表现以 及被访者对问题的反应。访谈也可以提供使用非语言指示进行帮助的机会。最后,基于亲身访谈的 临床诊断的有效性要高于用其他方法,比如电话调查的,完全只是因为亲身访谈可以获取更多的信 息(Acierno et al. , 2003)。 相比其他老年人虐待筛查工具,比如华莱克-森施托克老年人虐待筛查测试(H-S/EAST)6 ,它有 15个项目,EASI问题更少、只需更少的时间来完成(平均2分钟)。并且,在104名参与蒙特利尔研 究的医生中,95.8%的人将问题评为“非常容易”或“比较容易”,70.5%的人认为这些问题在发 掘老年人虐待问题上有一定的或者巨大的作用(Yaffe et al. , 2005)。 在蒙特利尔研究中,EASI的结果与社会工作评估表(SWEF) 7 相比较以评估效度 8 。这张表是在 更深层次上评估老年人受到虐待的风险的标准化社会工作评估。这张表包含67个问题,平均需要66 分钟来完成。第59问是比较验证EASI结果的“黄金标准”问题。在医生应用EASI的3周时间里,参 与研究的社工将评估表实施于老人们。访谈地点放在老人的家里或者一个被访者和社工双方都同意的安 全的谈话地点。EASI和SWEF的相关性达到敏感系数0.44以及特征系数0.77(Yaffe et al. , 2005) 9 。

6 具体例子请参考http://www.elderabusecenter.org/print_page.cfm?p=riskassessment.cfm 7 这张表由雷内卡森协会开发。 8 SWEF表在附件2中。 9 敏感系数指带有目标疾病的人群中检测呈阳性的人的比例。它用来协助评估和选择诊断测试/迹象/症状。特征系数是对应于阴性测试的指标,指没 有目标疾病的人群中检测呈阴性的比例。

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2.2 The Elder Abuse Suspicion Index EASI is an instrument that was developed and tested in Montreal by a research team from McGill University, St Mary’s Hospital Centre, CSSS René Cassin, and Sir Mortimer B Davis Jewish General Hospital, with funding from the Canadian Institutes of Health Research EASI consists of a few copyrighted, brief and direct questions (five questions for the patient and one for the physician) asked in the course of any office physician–patient encounter and formulated in doctor-friendly language. It is readily applicable to cognitively intact seniors (people aged 65 years and older) . The EASI was designed not necessarily to detect cases but to raise suspicion of the occurrence of elder abuse in order to justify referral to community experts in elder abuse such as social workers. A secondary aim was to help familiarize family doctors with elder abuse through the repeated use of a simple set of questions about elder abuse. Although EASI cannot guarantee detection of elder abuse or mistreatment, its application already indicates that the doctor is aware of elder abuse and may therefore refer potential cases to social and community services. The style of the EASI questions and application is along the lines of recommendations found in the relevant literature. The use of explicit, behaviourally specific closed questions, contextually orienting preface statements, and simultaneous assessment of both assault by strangers and abuse by family members/caregivers is appropriate for older adults. Moreover, there are several advantages of inperson interviewing: This permits visual assessment of both the respondent’s physical presentation and the respondent’s reactions to the questions. Interviews also offer opportunities for nonverbal indications of support. Finally the validity of clinical diagnosis made on the basis of inperson interviews is higher than that of other methods, such as telephone surveys, simply because more convergent (or divergent) lines of data are available to in-person interviewers (Acierno et al , 2003). Compared with other elder abuse screening tools, for example the Hwalek–Sengstock. Elder Abuse Screening Test (H-S/EAST), with originally 15 items, the EASI has fewer questions and requires less time to administer (on average two minutes). Furthermore, of the 104 doctors who participated in the Montreal study, 95.8% rated the questions as “very easy” to “somewhat easy”, and 70.5% considered the questions to have either some or a big impact on approaching elder abuse (Yaffe et al , 2005). In the Montreal study, results of the EASI were compared with a Social Work. Evaluation Form (SWEF) to validate the tool. This form is a standardized social work assessment to evaluate in greater depth older people at risk of being abused. The form comprises 67 questions and takes an average of 66 minutes to administer. Question 59 was the “gold standard” question to compare and validate the results of the EASI. Within three weeks of the application of EASI by physicians, social workers who participated in the study administered the evaluation form to seniors. The inter- view took place either at the older person’s home or in a safe place to talk that was mutually acceptable to the participant and the social worker. The correlation between the EASI and the SWEF reached a sensitivity rate of 0.44 and a specificity rate of 0.77 (Yaffe et al , 2005) .

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在蒙特利尔所作的这项研究的发现为后续研究提供了出色的基础。然而,原始的EASI项目关注 的只是发达城市社会中的家庭医生和老人的反应。而这次WHO-CIG项目的计划目标是探索其他文化 环境下的类似群体的反应,以及在全世界不同地理环境下测试一系列问题。因此,八个国家的专题 小组成员对蒙特利尔研究所使用的问题的评论意见最终发展了EASI10 。这是检验EASI在不同文化和 地理环境下的效度,并且评估它在加拿大以外地区的医生和老年病人中的接受程度与用处的过程中 的一步。

2.3 研究设计和方法 为了获得不同地理环境下关于具体问题的信息,方法上选择专题小组,因为这样做可以挖掘目 标小组中成员的信仰、态度和行为。另外,人们在专题小组讨论中通常会感到舒适,因为在大多数 社会中它都是一种自然的交流形式(Hudelson, 1994)。 参与者被邀请对于计划的问题是否合适、相关以及易于理解发表他们的观点。在这些发现的基 础上,培训模块、鉴别方法和干预策略将根据地方的情况进行开发或采用。 八个参与国家(澳大利亚、巴西、智利、哥斯达黎加、肯尼亚、新加坡、西班牙和瑞典)通过世 界卫生组织的专业联系被召集起来,并且根据以下的决定因素最后确认:

・与地方的协调员以及一个专题小组/研讨会协调员有合作的可能。 ・参与国家应当覆盖广大的地区。在这个项目中,非洲、南美、中美、欧洲、东南亚和西太平洋 地区被涵盖了。

・有提供地方支持和服务网络的跟进机制,以便于在定性研究后紧接着一个临床试点的阶段。 研究设计包括在每个国家管理7个专题小组来测试后来成为EASI的一系列12个问题。小组是按 如下方法区分的:

・3组老年人,进一步分解为一组老年女性、一组老年男性以及一组男女兼有。 ・4组基层医疗护理人员。 每一小组典型地由6到9人组成。两小时的专题小组讨论被录音、文字转录以及分析,每个国家 的发现最后被概括到一篇报告中。 另外,专门组织研讨会来测试社工对于SWEF的普遍反映,并收集老年人虐待问题的综合信 息,比如地方的评估与干预策略以及具体文化下的老年人虐待的分类。

10 在WHO-CIG专题小组研究中,根据研究者和WHO-CIG的合作备忘录,使用了蒙特利尔EASI项目中的材料。WHO-CIG专题小组使用的问卷基于 原始的EASI专题小组草案(见附件1),不过问题顺序有所改变并且对一些问题做了拆分。

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The findings of this study conducted in Montreal offer excellent groundwork on which to build further research. However, the original EASI project was focused on the reactions from family doctors and older people in the context of a developed urban society. The aim of the WHO-CIG project proposal was to explore the reactions of similar groups in other cultural contexts and to test a set of questions in geographically different settings across the world. Therefore, focus group participants in eight countries commented on the questions used by the Montreal researchers that ultimately led to the development of EASI. This was one step in the process of looking at the validity of the EASI in different cultural and geographical contexts and assessing its acceptance and usefulness among medical doctors and older patients in places other than Canada.

2.3 Research design and methodology In order to obtain information on specific issues that may vary from one geographical setting to another, focus groups were selected as a method because of their ability to explore beliefs, attitudes and behaviours in a target group. Furthermore, people usually feel comfortable in a focus group discussion because it is a form of communication found naturally in most communities (Hudelson, 1994). Participants were asked to express their opinions about whether the proposed questions are appropriate, relevant and understandable Based on these findings, training modules, identification methods and intervention strategies can then be developed or adapted according to local conditions. The eight participating countries (Australia, Brazil, Chile, Costa Rica, Kenya, Singapore, Spain and Switzerland) were engaged through professional links from WHO and identified according to the following parameters: •

Possibility of collaboration with a local coordinator and a focus group/work- shop facilitator.

Participating countries should cover a wide range of regions In this case, Africa, South America, Central America, Europe, South-East Asia and the Western Pacific Region were included.

Follow-up mechanisms should be in place to provide information on local support and service networks in case a piloting phase in clinical settings would follow the qualitative research.

The research design included the conduct of seven focus groups in each country to test the bank of 12 questions that led to the EASI The groups were split as follows: •

Three groups of older people, broken down further into one group of older women only, one group of older men only, and one group of both older men and women.

Four groups of PHC professionals. Each group ideally consisted of six to nine people The two-hour focus group sessions were tape-recorded, transcribed and analysed, and the findings from each country were summed up in a report. Furthermore, workshops were organized to test the general reaction of social workers towards the concept of the SWEF and to gather general information on issues of elder abuse, such as local assessment and intervention strategies and culturally specific categories of elder abuse. 22


在第二个研讨会中,观察基层医疗护理人员以及社工的反应,看他们认为泛美医疗组织 (PAHO)对虐待与忽视的指导方针有多少用处 11。这份手册可以在老年人虐待和忽视问题上为基层医 疗护理人员提供跟进和干预策略。这两个研讨会中收集的评论意见和反响同样都被概括收录与国家 报告。 WHO-CIG项目协调员为专题小组的执行提供所有必要的信息和文档,包括各部分提纲以及使 用表格。茶点或餐点、差旅费报销以及信息材料会提供给参与者。不含有其他形式的报酬。 总的来说,每个参与国家的活动有以下这些: 1. 4个由全科医师/PHC医生组成的专题小组:

・ 给医生看一系列12个问题(简要介绍)。 ・ 医生在一组小样本(15-20为病人)中试用这些问题以熟悉这个工具(可能的情况下) ・ 医生组成专题小组,对应用这些问题后的经验、观点和建议进行讨论。 ・ 报告。

12 。

2. 3个由老年人组成的专题小组:

・ 给老人们看一系列12个问题(简要介绍)。 ・ 老人组成专题小组,讨论对于12个问题的建议与观点。 ・ 报告。 3. 由社工组成的研讨会:

・ 向社工介绍SWEF。 ・ 和社工讨论,对于评估表在该国现实环境下有多少应用价值提出观点和看法。 ・ 报告。 4. 学习PAHO手册的混合研讨会:

・向医生和社工介绍PAHO培训模板。 ・对手册内容作专题小组讨论以及紧接着的研讨会安排。 ・报告。

11 这些指导方针来自于PAHO(2002),可以在附件3中找到。 12 由于项目日程非常紧迫,只有在智利和西班牙做了预采样。

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In a second workshop, reactions from PHC professionals and social workers were sought to see how useful the Pan American Health Organization (PAHO) guidelines on abuse and neglect were considered to be. This manual could be used as follow-up and intervention strategies for PHC professionals to use concerning the issue of elder abuse and neglect. The comments and reactions gathered in these two workshops were likewise summarized in the country reports. The WHO-CIG project coordinators provided all the necessary information and documentation for the conduct of the focus groups and workshops, including session outlines and administrative forms. Refreshments or a meal, reimbursement for travel, and information material was offered to the participants. Other forms of remuneration were not included. In summary, the activities in every participating country included the following: 1. Four focus groups with general practitioners/PHC doctors: •

Expose general practitioners to the bank of 12 questions (brief introduction).

General practitioners “pilot” the set of questions with a small sample (15–20 patients) to acquire familiarity with the instrument (where possible).

Focus group discussions with general practitioners on experiences, perceptions and suggestions after the application of the questions 16.

Report.

2. Three focus groups with older people: •

Expose older people to the bank of 12 questions (brief introduction).

Focus group discussions with older people on suggestions and perceptions of the 12 questions.

Report.

3. Workshop with social workers: •

Introduce social workers to the SWEF.

Workshop with social workers to seek their views and perceptions on how applicable the evaluation form is within the reality of the country.

Report.

4. Mixed workshop on the PAHO manual: •

Introduction of PAHO training model to general practitioners and social workers.

Focus group discussion following a workshop format on the content of the manual.

Report.

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由于老年人虐待是一种普遍的现象,所以项目的目标是不要介入任何的社会、性别或者种族歧 视。不过为了保护参与者的目的以及有利于总的研究,合理地提出了特定的排除准则。因此,具有 认知障碍的老年人不被包括在内。 在一些国家,要找到愿意参加专题小组的全科医生或者一线医生是一件困难的事。在这种情况 下,他们由护士、牙医以及老年病学家来替代。参与专题小组的老年人的年龄限制(65岁及以上)根 据不同国家对于“老年人”的定义,在某些地方(新加坡)被降低了。在巴西,“识字”成为了参与专 题小组讨论的老年人的一个附加准入条件。 专题小组讨论的目的是通过对12个项目中的每个项目询问以下问题,来寻求参与者的意见:

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 此外,在这部分最后,参与者需要选出他们认为可以纳入最终工具的最相关的5个问题。 项目协调员在每个参与国家指定了一位地方协调员来与日内瓦做定期的直接交流。这位协调员 指定一位具备定性研究方法论背景的地方促进员来组织和管理专题小组与研讨会、提供相关背景资 料、分析数据以及基于专题小组和研讨会结果准备最终国家报告。这些国家报告如果不是由英语写 的会被翻译成英语。然后,它们会被审阅,得出一份内容分析,来获取对于问题的反馈以及发现显 露出来的与老年人虐待的鉴别相关的主题和回答。根据这些讨论,对测试问题的以下发现将被系统 阐述,用于修改工具使之适合在八个参与国家中试点。

25


Since elder abuse is a universal phenomenon, the target of the project was not to apply any social, gender or ethnic discriminations to the study. Certain exclusion criteria are justified, however, with the purpose of protecting participants and for the overall benefit of the study. Therefore, cognitively impaired older people were excluded. In some countries, it was difficult to find general practitioners or front-line doctors willing to participate in the focus group discussions. In this case, they were replaced by nurses, dentists and geriatricians. The age limit for participants in the focus groups for older people (65 years and older) was lowered in some settings (Singapore) according to the national definition of “older person”. “Being literate” was an additional inclusion criterion in Brazil for the focus group discussion held with older people. The aim of the focus group discussions was to seek the participants’ opinions on each of the 12 items by asking: •

How important is this item in detecting elder abuse? How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

Furthermore, participants had to choose at the end of the session the five most relevant questions to be included in the final tool. The project coordinators identified a local coordinator in each participating country who was in direct regular contact with Geneva. This coordinator appointed a local facilitator with a background in qualitative research methodology to organize and conduct the focus groups and workshops, to provide relevant background information, to analyse the data, and to prepare the final country report based on the focus group and workshop sessions. These country reports were translated into English if they were written in a language other than English. Afterwards, they were reviewed and a content analysis was performed in order to obtain feedback on the questions and to discover emerging themes and answers relevant to the identification of elder abuse. Derived from these discussions, the following findings for the tested questions were formulated in order to adapt the instrument and to make it compatible for piloting in the eight participating countries 17.

26


3 发现与讨论 3.1 老年人专题小组 在一些国家,老年人参与者并不能清晰地理解专题小组讨论的目的以及评论或讨论问题的概念 (智利、肯尼亚)。这些小组不讨论既定内容以及选择5个最相关问题,取而代之的是讲述他们与各个 问题相关的经历13。西班牙的小组讨论的是另一套问题,因此在表格1中没有算入14。 与老年人的讨论中浮现出一系列普遍问题:

・身体虚弱的老人对于看护者的依赖会影响他们的回答。因此重要的是要私人地问这些问题。 ・全科医生的时间压力以及病人的成本使得一个更简短的问卷会更有效。缺乏训练也是一个问题。 ・在数个讨论中提出的一个基本问题就是当全科医生鉴别出一位有遭遇虐待的风险的病人时,他 需要有跟进策略。 在不同环境下的老年人选出的5个首选问题是问题4、5、6、8、11(根据选择次数多少排序): 表格1:老年人的5个首选问题 国家

题号 1

2

3

4

5

6

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

澳大利亚 巴西

7

8

9

10

11

x x

智利(N/A) 哥斯达黎加

x

x

肯尼亚(N/A) 新加坡

x

西班牙(N/A) 瑞士 N/A:不适用 15

13 专题小组规章,包括一套12个问题可以在附件1中找到。 14 适合应用于12个问题的评论依然被整合在了这个章节中。 15 有一些国家选择了6个问题,是由于有2到3个问题被认为同样重要,或者是由于参与者认为有必要保留6个而不是5个问题。

27

12


3 Findings and discussion 3.1 Focus groups with older people In some countries, the older participants did not clearly understand the purpose of the focus group discussions and the concept of commenting on or discussing the questions (Chile, Kenya). These groups talked about their experiences in relation to each question instead of discussing their content and choosing the five most relevant questions. The groups in Spain discussed a different set of questions and therefore are not taken into account in Table 1. A number of general issues emerged from the discussions with older people: •

Frail older people’s dependence on caregivers could influence their answers It is therefore crucial to ask these questions in private.

The pressure on general practitioners’ time and the cost to the patient would make a shorter questionnaire more useful Lack of training was also a concern.

An essential issue that was brought up in several discussions was the need for GPs to have follow-up strategies for a general practitioner when they identify a person at risk of being abused.

The five preferred questions chosen by the older people in the different settings were Questions 4, 5, 6, 8 and 11 (in order of number of responses): Table 1 Five preferred questions of older people Country

Question number 1

2

3

4

5

6

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

Australia Brazil

7

8

9

10

11

x x

Chile (N/A) Costa Rica

x

x

Kenya (N/A) Singapore

x

Spain (N/A) Switzerland N/A, not applicable

28

12


问题的措辞被认为有些不自然,并且有时太“临床”。措词“阻止”看来是一个糟糕的用词: 人们建议“剥夺”(新加坡)或者“否决”(西班牙)将会是更好的替代。另一些表达比如“基本日常需 求”(澳大利亚、巴西、新加坡)、“充足的生活空间”(哥斯达黎加)以及“限制你的自由活动”(澳大 利亚)看来令人费解。“健康辅助器”和“助听器”可以被省略(哥斯达黎加、新加坡)。某些问题包 含了太多不同的观点并且太冗长了(例如问题4)。还有一些问题太笼统了(问题10),可以结合具体案 例详述。为了使得问题简单直接,每个项目应该只提出一个观点。比如说,问题6询问了不同的三件 事:(i)被占便宜,(ii)被阻止做事情以及(iii)干预自己与要好的同伴呆在一起。 问题总的来说被认为全面覆盖了老年人虐待的关键部分。然而仍有一些形式的虐待,比如情感 虐待、忽视(新加坡)、食物剥夺以及照顾小孩的负担被认为是相关的问题但是没有被具体提出。另 外,社会性虐待,表现形式为“年龄歧视”,是一个重复出现的主题。参与者们常常表达出对那些 微妙的、或者有时候不那么微妙的社会看待老年人的方式的改变,随着年龄增长将他们看做“越来 越次要的人”的担忧,并且认为这构成了虐待。 问题2和问题3,涉及寻求帮助以及依赖的问题,是好问题。但是大多数老年人觉得要承认自己 需要帮助或者依赖他人是一件困难的事情。 有人指出老年人和一位熟悉的医生始终保持亲近的关系已经越来越困难。然而询问某些问题(例 如问题12)需要依靠病人和医生间的信任关系以及医生敏锐地询问问题的技巧才能鼓励病人信任医 生。 另有一些问题不能在所有文化环境下被询问。普遍认为关于性虐待的问题(问题12)可能会很无 礼,所以不应该对所有人询问。在肯尼亚,关于性的问题被认为是一个非常微妙的话题,不适合与 陌生人甚至是熟悉的医生谈论。人们建议这个问题应该仅当已经发现了一些性虐待的嫌疑才提出询 问。 根据地理环境不同,一些问题更加受到重视。酒精依赖的问题在哥斯达黎加和肯尼亚被认为相 关得多,相比于其他国家。有人还建议将毒品滥用包含进这个问题。问题7,和财产虐待的风险相 关,被巴西的专题小组参与者认为是最重要的问题之一。同时在肯尼亚,经济依赖被识别为一个高 风险因素,因为几乎所有家庭都依靠老年双亲提供食物、衣物、日常经费和医疗服务的经济支持。 然而这个问题在其他国家被认为不那么重要。老年人照顾小孩的负担在肯尼亚受到压倒性的关注, 却并没有直接出现的问题中。巴西的老年男性与女性混合小组觉得医生没必要关注“被占便宜”的 问题,因为这被认为只是巴西人习以为常的日常问题。

29


The wording of the questions came across as somewhat stilted and sometimes too “clinical”. The term “prevented” appears to be a poor choice of word: It was suggested that “deprived” (Singapore)21 and “denied” (Spain) would be better alternatives. Other expressions such as “basic daily needs” (Australia, Brazil, Singapore), “adequate living space” (Costa Rica) and “impeded your free movement” (Australia) appeared to be incomprehensible. “Health aids” and “hearing aids” can be omitted (Costa Rica, Singapore). Some of the questions include too many different ideas and are too wordy (e.g. Question 4). Other questions were too general (Question 10) and could be elaborated better with specific examples. In order to make the questions simple and straightforward, only one idea should be addressed within each item. For example, Question 6 asks about three different things: (i) being taken advantage of, (ii) being prevented from doing things and (iii) interference with being with the people you wanted to be with. The questions were, in general, considered to be comprehensive in covering all key areas of elder abuse. Some forms of abuse, however, such as emotional abuse, neglect (Singapore), deprivation of food and the burden of child care, were considered relevant issues that were not addressed specifically. Also, societal abuse, in the form of “ageism”, was a recurring theme. The subtle, and sometimes not so subtle, changes in the way older people are regarded by society as being “less of a person” as they age were an often-expressed concern that was considered by participants to constitute abuse. Questions 2 and 3, tackling the issues of asking for help and dependence, are good questions, but most older people would find it hard to admit that they need help or depend on somebody. It was pointed out that it is becoming less likely that older people have a consistent and close relationship with a doctor they know; some questions (e.g. Question 12), however, require a trusting relationship between the patient and the doctor and depend on the doctor’s skills to ask the questions in a sensitive way that would encourage people to trust them. Other questions cannot be asked in all cultural contexts. It was a general comment that the question about sexual abuse (Question 12) would be very confrontational and should not be asked of all people. In Kenya, the issue of sex is considered to be a topic that is too delicate to be discussed with a stranger or even a doctor known to the person. It was suggested that this question should be asked only if there is already some suspicion of sexual abuse. Depending on the geographical setting, some questions were given more weight and emphasis. The question on alcohol dependence was considered much more relevant in Costa Rica and Kenya than in other countries. It was also suggested that drug abuse be included in this question. Question 7, relating to the risk of financial abuse, was considered as one of the most important questions by the Brazilian focus group participants. Also in Kenya, financial dependence was identified as a highrisk factor, since almost all households depend on older parent(s) for financial support for food, clothing, fees and medical care. The issue was regarded as less important in other countries, however. The burden of child care on older people appears to be an overwhelming concern in Kenya that was not addressed directly by the questions. The Brazilian group of older men and women felt that physicians should not be concerned with the concept of “being taken advantage of”, as this was considered a daily issue to which people in Brazil are used. 30


3.2 基层医疗护理人员专题小组 组织医生的专题小组遭遇了困难,因为只有很有限的人(澳大利亚、肯尼亚、新加坡)甚至没有人 (智利)愿意参加进小组。在一些国家他们(部分地)由护士(澳大利亚、智利)或者牙医(肯尼亚)代替。 通过讨论得到了一些普遍的观点:

・术语“老年人虐待”有负面的暗示并且会引起恐惧和焦虑,即使是面对医疗护理人员,所以可 能有必要寻找其他术语来替代它。

・有必要在提问之前判断老年病人是否有认知衰退,因为这项问卷不能对有认知障碍的病人使用。 ・这些问题不能在潜在的施虐者面前提出,例如一位看护者。 ・所有这些问题应当通过对话的方式而不是问卷或者一览表的方式提出。医生可能没有足够的时 间来提这些问题。或许在一些场合下,护士可以管理执行问卷。

・提出这些问题的同时需要进行身体检查来作为筛查的一部分。 ・基层医疗护理人员在管理执行问卷的同时,需要熟悉不同的老年人虐待的分类,以及跟进和干 预的策略。

・如果发现了有根据的虐待嫌疑,但是可能的受害者不愿意告发施虐者或者不愿被送交,基层医 疗护理人员应该做出怎样的反应以支持进一步行动? 在不同环境下的基层医疗护理人员选出的5个首选问题是问题4、8、5、11、12: 表格2:基层医疗护理人员的5个首选问题 题号

国家 1

2

3

4

5

6

7

8

9

x

x

x

x

x

澳大利亚

x

巴西

x

x

智利

x

x

x

哥斯达黎加

x

x

x

x

x

x

肯尼亚

x

x

10

11

12

x

x

x

x

x x

x

新加坡

x

x

x

x

x

西班牙

x

x

x

x

x

x

x

x

x

瑞士

x

31

x


3.2 Focus groups with PHC professionals The organization of focus groups with physicians caused difficulties as only a limited number (Australia, Kenya, Singapore) or none (Chile) were willing to participate in the groups. In some countries they were re- placed (partly) by nurses (Australia, Chile) or dentists (Kenya). Some general comments were made throughout the discussions: •

The term “elder abuse” has a negative connotation and elicits such fear and anxiety, even among health-care professionals, that there may be a need to look for other terms that can be used to replace it.

It is essential to determine whether or not there is a cognitive deterioration in the older patient before asking such questions, as this questionnaire cannot be used when a patient is cognitively impaired.

These questions should not be asked in front of the potential perpetrator, e.g. a caregiver.

All of these questions should be asked in a conversational way rather than like a questionnaire or checklist. Physicians may not have enough time to ask these questions Alternatively, in some situations, nurses could administer the questionnaire.

Asking these questions would also require physical examination as part of the screening.

PHC professionals need to be familiar with the various categories of elder abuse, and follow-up and intervention strategies, when administering this questionnaire.

How should a PHC professional react if there is substantiated suspicion of abuse but the potential victim is not willing to denounce the perpetrator or to be referred for further action?

The five preferred questions chosen by the PHC professionals in the different settings were Questions 4, 8, 5, 11 and 12:

Country 1 Australia Brazil Chile Costa Rica Kenya Singapore Spain Switzerland

x

Table 2 Five preferred questions of PHC professionals Question number 2 3 4 5 6 7 8 9 10 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

32

11 x x x x x x x

12 x x x x


总的来说,问题被认为是有用的,因为这项工具比其他的工具更简短并且有助于提高认知。同 时,老年人虐待的所有的关键部分都被覆盖到了。孤独问题、基本生存条件依赖他人、被虐待、易 受到强权方的伤害、被占便宜、巨大的经济责任以及在脆弱的状态下担当看护者这些现今的重要议 题被纳入的问题中。然而为了能更有效地使用问卷,人们建议缩短它并简化措辞。 这些问题显得太过正式并且令人费解。有一定数量的术语太艰深而不适用,比如“充足的生活 空间”(澳大利亚、巴西、智利、新加坡)、“自由活动”(巴西)、“不想要的接触”(巴西)、“健康 辅助器”(智利)、“基本日常需求”(澳大利亚、巴西、新加坡、西班牙)和“占便宜”(新加坡)。另 有一些表达不够具体,比如“需要的东西”(澳大利亚)。 一些问题应当被分割开来,因为它们包含了互不相关的不同概念。举例来说,问题4同时询问了 基本需求和高级需求。问题5在一句话里询问了不同的情绪(“难过、羞愧、恐惧、焦虑以及不高 兴”)。在问题8中,提出了两个不同的问题:滥用钱财以及被迫签署文件。另有一些问题可以合并 起来,比如问题2和问题3,以及问题11和问题12。 一些用词很难被翻译成其他语言,例如,“dependent”(问题3)的等价词在汉语中不存在。 总的来说,将某些表达翻译成巴西葡萄牙语或者将整个问题翻译成马来语、汉语及其方言是非常具 有挑战性的16。 普遍的将问题看做一个整体的评论建议将问题的第二部分(如果有的话)省略掉(即:“这是一次 孤立的事件还是不止发生过一次?”)(澳大利亚、巴西、新加坡、西班牙)。然而了解这是不是一次 孤立的事件还是一种现存的/长期行为模式的一部分是重要的,尤其是在侦测虐待嫌疑时。此外,问 题的时间线并不是很清楚:应该把关注点集中在近期、或者几年或多年前发生的事件还是甚至一生 中发生过的事件?还有一个建议是增加一个部分询问与施虐者的关系(哥斯达黎加、西班牙)。 和与老年人的讨论相似,有人提到许多老年人寻求帮助时会感到不适,可能是由于他们希望独 立处理问题,或者由于他们害怕被拒绝。这个因素使得鉴别虐待变得更加困难,因为一些人可能害 怕施虐者的不良反应而不充分地回答问题。基于医疗从业者对老年病人的社会或者家庭背景以及家 庭关系的事先了解之上,而建立的医生与病人的信任关系就变得格外重要。而且,一些问题(例如问 题12)需要数次与医生的会面才能被提出(澳大利亚、新加坡)。

16 对于新加坡小组而言,问题是翻译成汉语的,因为大多数新加坡人是华裔并且说的是汉语及其方言而不是英语。

33


Overall, the questions are considered useful as the instrument is shorter than other tools and helps in raising awareness. Also, all of the key areas of elder abuse are covered. Issues of loneliness, dependence on others for their basics, being mistreated, being vulnerable at the hands of the powerful, being taken advantage of, overwhelming financial responsibility and being caregivers in their state of fragility are critical issues today that the questions capture. In order to be used effectively, however, it was recommended that the questionnaire was shortened and its wording simplified. The questions appeared to be overly formal and convoluted. There are a number of terms that are too difficult to apply, such as “adequate living space” (Australia, Brazil, Chile, Singapore), “free movement” (Brazil), “unwanted approaches” (Brazil), “health aids” (Chile), “basic daily needs” (Australia, Brazil, Singapore, Spain) “and taking advantage” (Singapore) Other expressions are not specific enough, such as “needed things” (Australia). Some of the questions should be separated as they contain different concepts that are not related to one another. For instance, Question 4 inquires about both basic and secondary needs. Question 5 asks about different emotions (“sad, shamed, fearful, anxious or unhappy”) in one sentence. In Question 8, two different issues are addressed: misuse of money and being forced to sign documents. Other questions could be combined, such as Questions 2 and 3 and Questions 11 and 12. Some words are difficult to translate into other languages, e.g. an equivalent for “dependent”(Question 3) does not exist in Mandarin. Generally, it was challenging to translate some of the expressions into Brazilian Portuguese and to translate whole questions into Bahasa Melayu. and Mandarin and its dialects. General remarks looking at the questions as a whole recommended that the second part of each question (where applicable) could be omitted (i.e. “Was this an isolated event or has it occurred more than once?”) (Australia, Brazil, Singapore, Spain). It is important, however, to get some idea of whether this is an isolated incident or part of an existing and/or long-standing pattern, even in detecting suspicions of abuse. Furthermore, the time frame of the questions is not clear: should the main focus be on recent situations or on events that happened several or many years ago or even within a lifetime? Another suggestion was to add a part asking about the relationship with the perpetrator (Costa Rica, Spain). Similar to the discussions with older people, it was mentioned that many older people feel uncomfortable when requesting help, either because they want to stay independent or because they are afraid of being rejected. This factor renders it more difficult to identify abuse, as some people may not answer the questions fully because they fear repercussions by the perpetrator. A trusting relationship between the physician and the patient, where the medical practitioner has prior knowledge of the social or home situation and family relationships of the older patient, is crucial Moreover, some of the questions (e.g. Question 12) would require several visits to the doctor before they can be asked (Australia, Singapore).

34


尽管对老人的性虐待是一个需要被包括进去的范畴,但如果一个未经训练的人员对老人提出这 个问题反而可能会对老人的感情造成伤害。此外,有人怀疑人们是否会愿意回答这样一个直接而微 妙的问题(哥斯达黎加、肯尼亚、西班牙)。同时,性别方面也有人强调:有人指出在一些国家男性医 生向老年女性提出这个问题会很困难(新加坡)。 阻止某人做某事的概念需要进一步阐明(问题4):有时候老年父母的需求不能被满足是因为财产 资源和渠道的不足(哥斯达黎加、新加坡);而有时候生活经历或者健康问题减少了老年人的行动自由 和选择权利,比如说家人或医生建议老人停止再开车(澳大利亚)。对老年人需要的某种东西的剥夺因 此未必是一种虐待,尽管这要视需求是什么而言。另外,应该进一步具体确定问题涉及的是个人还 是一个抽象实体,例如社区(西班牙)。 问题11被认为含糊不清因为并不清楚这一项问题指涉的是意外伤害(比如将某人抬到轮椅或者浴 缸而发生的摔倒或者挫伤)还是故意伤害(故意粗暴或暴力对待)。 在老年人专题小组中,根据地理环境的不同一些问题会被认为重要。关于酒精依赖的问题9在参 与者中就形成了分化。在澳大利亚、智利和哥斯达黎加,这个问题比在其他国家得到了更高的重要 性评价。同时看护者或家庭成员的吸毒和赌博成瘾也可以被加入这项问题(澳大利亚)。然而,有人指 出酗酒本身并不应该自动被视为老年人虐待的风险因素,不过它可能会加剧虐待环境的发展和持续 而因此提高了虐待存在与发生过的嫌疑。 问题没有涉及到的议题包括药物约束(澳大利亚)、以暴力威胁(澳大利亚)、介入决定过程(澳大 利亚)、遗弃(哥斯达黎加)以及忽视(新加坡)。 对于问题的顺序只有少数评论。大部分情况下都是建议保留原来顺序或者调换开始几个问题的 顺序。

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Although sexual abuse of older people is a category that needs to be included, it may be detrimental to the well-being of an older person if an untrained person asks about the issue. Furthermore, there were doubts about whether people would be willing to answer such a direct and delicate question (Costa Rica, Kenya, Spain). Also, the gender dimension was emphasized: It was pointed out that it would be difficult in some countries if a male GP asked an older woman about this issue (Singapore). The concept of preventing somebody from something needs further clarification (Question 4): At times the necessities of older parents cannot be met because of a lack of financial means and resources (Costa Rica, Singapore), and sometimes life events or health problems curtail the freedoms and choices of older people, such as advice from family or doctors to cease driving a car (Australia). The deprivation of something that is needed by an older person is therefore not necessarily an abuse, although this depends on the definition of need that is being used. Additionally, it should be further specified whether the question refers to a person or an abstract body, for example the community (Spain). Question 11 was considered ambiguous as it is not clear whether this item refers to accidental harm (such as a fall or bruise when transferring someone into a wheelchair or bath) or intentional harm (being intentionally rough or violent). As in the groups with older people, some questions are considered important according to the geographical context they are asked in. Question 9 on alcohol dependence polarized participants. More significance was attached to the question in Australia, Chile and Costa Rica than in other countries. Also illicit drug-taking and gambling addictions by caregivers or family members could be added to this item (Australia). However, it was pointed out that drinking too much alcohol should not be considered automatically as a risk factor for elder abuse, but it may be implicated in the development and perpetuation of abusive situations and therefore should act to raise suspicions that abuse exists or has taken place. Issues that were neglected in the questions were chemical restraint (Australia), threatened physical violence (Australia), involvement in decision-making (Australia), abandonment (Costa Rica) and neglect (Singapore). There were only a few comments on the order of the questions. In most cases it was suggested to leave the order as it is or to reverse the order of the first few questions.

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3.3 研究结果对于EASI工具的启示 国家协调员们在一次会议中发表了专题小组研究的发现,并且讨论了建议和结论。两位来自蒙 特利尔小组的研究者也参与了这次会议。 这次会议中,这套12个问题与原始的EASI17 (5个给病人的问题以及1个给医生的问题)做了比 较。基于对12个问题的研究结果,大家一致认为EASI是一个好的简单的工具,覆盖了所有重要的虐 待类型。它的用词适合加拿大以外的文化地理环境。EASI的问题1询问老人是否需要帮助,并且介 绍了可能存在风险的情境。问题2询问是否发生过任何类型的剥夺。问题3涵盖心理与言语虐待。问 题4是关于财产虐待。问题5处理身体与性虐待。问题6a是一个观察员问题,以及问题6b是关于私 密性以及诚实性的问题,只用于研究目的。WHO-CIG研究项目的国家发现指出,在大多数专题小组 讨论中,同样的问题被选为最相关。以下的问题列表对两套问题做了对应: 问题2(EASI): 2 有没有谁曾阻止你获取食物、衣服、药品、眼镜、助听器或者医疗护理,或者不让你与要好 的同伴呆在一起? 与问题4(WHO-CIG专题小组问题18): 4 有没有谁曾阻止你拥有需要的东西,比如食物、药品、衣服、充足的生活空间,或者健康辅 助器比如眼镜、助听器等等? 问题3(EASI): 3 有没有谁对你说话的方式曾让你感到羞愧或者感觉受到威胁,使你很难受?

问题5(WHO-CIG专题小组问题): 5 有没有哪位你亲近的人曾无缘无故对你大喊大叫,或者用你不喜欢的方式与你说话,或者让 你觉得特别难过、羞愧、害怕、焦虑或者不高兴——因此让你难受很长一段时间?

17 见54-56页 18 另见附件1。

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3.3 Implications of the results for the EASI tool The country coordinators presented the focus group findings at a meeting where recommendations and conclusions were dis- cussed. Two researchers from the Montreal team also participated in the meeting. At this meeting, the set of 12 questions was compared with the original EASI (5 questions for the patient and 1 question for the physician). Based on their study results for the 12 questions, the group agreed that the EASI was a good and simple tool that covers all the important abuse categories. Its wording is appropriate for cultural and geographical contexts other than Canada. Question 1 of the EASI is a way of asking older people if they need help and to introduce potential situations of risk. Question 2 enquires about whether any kind of deprivation is taking place. Question 3 covers psychological and verbal abuse. Question 4 is about financial abuse. Question 5 tackles physical and sexual abuse. Question 6a is an observer question and Question 6b is a question about privacy and honesty and is only for research purposes. The country findings of the WHO-CIG study indicate that in most focus group discussions, the same questions were chosen as most relevant. The following questions correspond to each other between the two sets of questions: Question 2 (EASI): 2 Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with? and Question 4 (WHO-CIG focus group questions): 4 Has anyone prevented you from having needed things such as food, medication, clothing, adequate living space, or health aids such as eyeglasses, hearing aids, etc ? Question 3 (EASI): 3 Have you been upset because someone talked to you in a way that made you feel shamed or threatened? and Question 5 (WHO-CIG focus group questions): 5 Has anyone close to you unfairly yelled at you, or talked to you in ways that you did not like, or made you feel especially sad, shamed, fearful, anxious, or unhappy – in a way that left you upset for a long time?

38


问题4(EASI): 4 有没有谁曾试图强迫你签署文件或者违背你的意愿使用你的钱?

问题6和问题8(WHO-CIG专题小组问题): 6 有没有哪位与你亲近的人曾让你觉得被占便宜,或者阻止你做对你自己很重要的事情,或者 干预你和要好的同伴呆在一起?

8 有没有哪位你曾信任的人用你不想要的方式使用或者试图使用你的钱、财产或房产,或者强 迫你签署你并不理解或者不想要签署的文件? 问题5(EASI): 5 有没有谁曾让你害怕,用你不想要的方式触碰你,或者伤害你的身体?

问题11和问题2(WHO-CIG专题小组问题): 11 有没有谁曾伤害你的身体,例如击打你、推你或者限制你的活动自由?

12 有没有谁曾用你不想要的方式触碰你,或者在你不情愿的情况下作性接触,以至于让你感 到难受? 通过观察EASI问题,产生了一些评论意见。对于问题2有人提到,剥夺的类型取决于文化环境 并可能需要修改。此外,有人讨论“悲伤”是否应该包含在问题3中,不过项目组决定“悲伤”不是 一种与虐待情境有必然联系的情感。关于“忽视”的议题并没有在整个问卷中充分提到。也有人建 议对所有项目去掉“这样的事情发生过一次以上吗?”的问题。另外,对EASI作了一些微小的改动 建议(在下面用加粗字突出): 对象编号:☐ ☐ ☐ ☐ ☐ ☐ 医生编号:☐ ☐ ☐

39


Question 4 (EASI): 4 Has anyone tried to force you to sign papers or to use your money against your will? and Question 6 and Question 8 (WHO- CIG focus group questions): 6 Has anyone close to you made you feel that you were being taken advantage of, or prevented you from doing things that were important for your well being, or interfered with you being with the people you wanted to be with?

8 Has anyone that you would trust used or tried to use your money, possessions or property in ways that you did not want, or forced you to sign documents that you did not understand or did not want to sign? Question 5 (EASI): 5 Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically? and Question 11 and Question 12 (WHO- CIG focus group questions): 11 Has anyone physically hurt you, for example has hit you, pushed you or has impeded your free movement?

12 To a degree that it upsets you, has anyone touched you in ways you did not like, or made unwanted sexual approaches? By looking at the EASI questions, a few comments were made. For Question 2 it was mentioned that types of deprivation depend on the cultural context and may need modifications. Furthermore, it was discussed whether “sad” should be included in Question 3, but the project group decided that “sad” is not an emotion that is necessarily associated with situations of abuse. The issue of “neglect” was not addressed adequately in the whole questionnaire. It was also suggested to take out all cases of “Has this happened more than once?”. Moreover, a few minor modifications were recommended for the EASI (highlighted below in yellow): Subject No ☐ ☐ ☐ ☐ ☐ ☐ Doctor No ☐ ☐ ☐

40


对病人的指导: 我现在要进入到你同意参加的研究部分。(如果有陪同人员,对她/他说:由于研究人员要求这 部分由私人完成,能请你离开一小段时间吗?)(如果陪同人员不离开,那继续问问题,不过要在之后 记录下他/她的在场)我现在将会询问一些你在最近12个月里面发生过的生活状况和人际关系。请试 着仅仅用“是”或者”不是“来回答每一个问题,虽然这可能有点困难。 1 你在以下任何一件事上是否需要依赖他人:洗澡、着装、购物、办理银行业务或者用餐? ☐ 是

☐ 否

☐ 没有回答

如果回答是:你与所依赖的那些人之间会经常发生问题吗? ☐ 是

☐ 否

☐ 没有回答

2 有没有谁曾阻止或试图阻止你获取食物、衣服、药品、眼镜、助听器或者医疗护理,或者不让你 与要好的同伴呆在一起? ☐ 是

☐ 否

☐ 没有回答

如果回答是:这样的事情发生过一次以上吗? ☐ 是

☐ 否

☐ 没有回答

3 有没有谁对你说话的方式曾让你感到羞愧或者感觉受到威胁,使你很难受? ☐ 是

☐ 否

☐ 没有回答

如果回答是:这样的事情发生过一次以上吗? ☐ 是

☐ 否

☐ 没有回答

4 有没有谁曾试图强迫你签署文件或者违背你的意愿使用你的钱或财产? ☐ 是

☐ 否

☐ 没有回答

如果回答是:这样的事情发生过一次以上吗? ☐ 是

☐ 否

☐ 没有回答

5 有没有谁曾让你害怕,用你不想要的方式触碰你,或者伤害你的身体? ☐ 是

☐ 否

☐ 没有回答

如果回答是:这样的事情发生过一次以上吗? ☐ 是

☐ 否

☐ 没有回答

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Instructions to patients: I am now going to move to the research study in which you have agreed to take part (If there is an accompanying person say to her/him: Since the researchers ask that this be done in private, would you please leave us for a few moments?) If accompanying person does not leave, ask questions anyway, but record below his/her presence... I will now ask about life situations or relationships that may have occurred over the last 12 months. While it may be difficult to do, please try to answer each question with only the words Yes or No. 1 Have you relied on people for any of the following: bathing, dressing, shop- ping, banking or meals? ☐ Yes

☐ No

☐ Did not answer

If Yes: Have problems been common between those people and you? ☐ Yes ☐ No ☐ Did not answer 2 Has anyone prevented you or tried to prevent you from getting food, clothes, medication, glasses, hearing aides or medical care, or from being with people you wanted to be with? ☐ Yes

☐ No

☐ Did not answer

If Yes: Has this happened more than once? ☐ Yes

☐ No

☐ Did not answer

3 Have you been upset because someone talked to you in a way that made you feel shamed or threatened? ☐ Yes

☐ No

☐ Did not answer

If Yes: Has this happened more than once? ☐ Yes

☐ No

☐ Did not answer

4 Has anyone tried to force you to sign papers or to use your money or your belongings against your will? ☐ Yes

☐ No

☐ Did not answer

If Yes: Has this happened more than once? ☐ Yes

☐ No

☐ Did not answer

5 Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically? ☐ Yes

☐ No

☐ Did not answer

If Yes: Has this happened more than once? ☐ Yes

☐ No

☐ Did not answer

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医生:不要对病人询问以下问题。这仅仅由你本人作答。

6a 老年人虐待可能与以下的发现有关:缺乏眼神交流,孤独的性格,营养不良,卫生问题,伤口, 青肿,不合体的着装,用药依从性问题。你今天或者12个月以内有任何以上发现吗? ☐ 是

☐ 否

☐ 不确定

6b 医生:除了你和病人之外,在提问的过程中还有其他人在这个房间中吗? ☐ 是

☐ 否

M J Yaffe, MD mark.yaffer@mcgill.ca M Lithwick, MSW mlithwick@ssss,gouv.qc.ca C Wolfson, PhD tinaw@epid.jgh.mcgill.ca

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Doctor: Do not ask this next question to the patient It is for you only to respond to. 6a. Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or within the last 12 months? ☐ Yes

☐ No

☐ Not sure

6b. Doctor: Aside from you and the patient, is anyone else in this room during this questioning? ☐ Yes

☐ No

M J Yaffe, MD mark.yaffe@mcgill.ca M Lithwick, MSW mlithwick@ssss.gouv.qc.ca C Wolfson, PhD tinaw@epid.jgh.mcgill.ca

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3.4 社工研讨会 来自不同国家的参与者似乎都有一个共识,那就是无论地处哪里,老年人虐待都是一个重要的 社会问题。同时,以不尊敬和漠视老人为表现形式的年龄歧视问题,也是几乎所有小组中的一个突 出主题。尽管如此,资源和社会支持在大多数情况下还是很有限。政府参与不足影响着所有参与国 家,表现为目前生效的与医疗卫生、社会问题和财政相关的公共政策都没有充分地保护老年人(澳大 利亚、巴西、智利、哥斯达黎加、肯尼亚、西班牙)。 参与者讨论了在具体文化下老年人虐待的风险因素,并做出了以下分类:

・家庭成员牵涉毒品交易(巴西)。 ・在贫民窟居住增加了危险性和限制自由行动导致的孤立性,由于充满暴力的环境(巴西)。 ・如果发现巫术嫌疑(例如在肯尼亚的基西地区),一般总是老年人而不是年轻人受到指控。许多老 年妇女被当众烧死,不管有没有“证据”(肯尼亚)。

・与其他参与国家不同,在肯尼亚,老年人口在全体人口中与儿童人口相比数量很低,使得分配 给老年人的资源数量非常有限。

・使用医疗护理设施和咨询服务对于居住于偏远地区的老年人通常是不可行的,因为他们无法长 距离行走或者付不起交通费用(哥斯达黎加、肯尼亚)。

・健康保险基金的歧视:在肯尼亚,举例来说,国家健康保险基金只接受75岁以下的人加入。而 且,保险公司要求老年人支付高得多的保险金,从而将他们拒之门外并使他们处于很不利的境 况。 也有人提到其他的发生在社工经历中的虐待的类型:

・ 家庭成员代替老年人做决定。 ・ 用传统文化期望来为虐待行为作辩解。 ・ 实行虐待的威胁和恐吓可能成为强有力的控制手段。 ・ 扣留信息来对老人进行惩罚或者占便宜。

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3.4 Workshop with social workers There seems to be a general consensus among the participants from the different countries that elder abuse is an important community issue, regardless of the geographical setting. Also ageism, in the form of disrespect and disregard of older people, was a theme that was prominent in almost all groups. Nonetheless, resources and community support are in most cases limited. Insufficient engagement on behalf of the government affects all participating countries, expressed by prevailing public policies relating to health care, social issues and finance that do not adequately cover or protect older people (Australia, Brazil, Chile, Costa Rica, Kenya, Spain). The participants discussed culturally specific risk factors for elder abuse and developed the following categories: •

Family members who are involved in drug dealing (Brazil).

Living in a favela of vulnerability and isolation by restrict- ing free movement due to the violent environment (Brazil).

When witchcraft is suspected (e.g. among the Kisii of Kenya), it is always older people, rather than young people, who are accused Many older women are burnt to death by the public, with or without “evidence” (Kenya).

Unlike in other participating countries, in Kenya the low number of older people in the total population, compared with children, leads to a very limited amount of resources being allocated for older people.

Access to health care facilities and counseling services is usually not available for older people living in remote areas as they cannot walk long distances or afford transportation (Costa Rica, Kenya).

Discrimination by health insurance funds: In Kenya, for example, the National Health Insurance Fund accepts membership only below the age of 75 years In addition, insurance companies demand much higher premiums from older people, thereby locking them out of insurance and putting them at great disadvantage.

There were also mentioned additional abuse categories that arose within the social workers’ experience: •

Decisions were made by family members and not by the older person.

Use of cultural expectations to justify abusive behaviour.

The threat of abuse and intimidation can be a potent controlling force.

Withholding of information to punish or to take advantage of an older person.

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所有参与国家都存在关于家庭暴力的政策、规章和培训,但不是在所有社会公共机构都可以获 得指导方针或者提供培训设施(巴西、智利、哥斯达黎加、肯尼亚)。即使有这样的渠道,培训也往往 是不正规、不标准、不系统或者不强制性的。有时候老年人虐待被包含在了更一般的培训和工作规 章制度中(巴西、智利、肯尼亚、西班牙)。作为结果,社工只能使用他们在妇女儿童家庭暴力领域的 专业培训和经历并使之适应对老年人的工作。在新加坡,许多关于老人的决定需要家庭的一致同 意。因此一线的社工必须从家庭的角度来审视情况。此外,不同职业间的协调被认为是干预的关 键,但往往还很缺乏或者需要提高。 SWEF(社会工作评估表)普遍被研讨会参与者们认为是一个很全面和详细的评估工具。尽管如 此,对于它的应用性还是有不同意见。好的地方在于它的广泛性,覆盖了许多社工需要了解的因 素、问题和主题。因此它可以作为一个良好的推广工具以及一个培训资源。 在大多数国家(澳大利亚、巴西、哥斯达黎加、新加坡、西班牙、瑞士)要应用这张评估表都被 认为是不可行的。表的长度成为了主要的挑战,同时包括了实践上和理论上的困难。另一个关键问 题是对许多问题要获得如实的回答的难度:许多人会尽力轻描淡写他们所遇到的问题以避免麻烦。 在一些国家,社工的日程不包括定期的家庭访问,因此要核实一个人的在家的情况是不可能的。在 执行问卷的人和被访者之间有必要建立一个非常坚实的信任关系,但是要建成这种关系至少要经历 一段的时间。表中的一些用词和提问风格被认为在一些国家会受到限制或者不适用(智利、新加坡、 西班牙、瑞士)。 另外,参与者对于这张表能否应用于有认知障碍的人持保留意见。对人过度评估的问题也有人 提出,因为已经有许多评估工具已经在使用中。也有人强调“虐待”与“忽视”这样的标签通常不 会被社工使用。社会工作干预的目标被看作是提高老年人的生活质量,而不是谴责或者标记某个人 为“虐待者”或者“受害者”。 对于该表的应用性的另一方面质疑是关于干预问题。这张表与干预方案有什么关联?随表附带 一个评估嫌疑的手册以及一张根据地区改编的干预可能方案流程图被认为是很有必要的。这张表也 被认为没有提供足够的空间因而限制了做评估的社工的进一步探究。此外,干预的可能方式也取决 于现存的法规。即使有干预命令,它们也很难被频繁地执行,因为部分受害者不愿意不断地举报施 虐者(通常是亲近的人)、老人身体较脆弱以及有时候警察部门缺乏理解和/或处理这种境况的能力。

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Policies, protocols and training on family violence exist in all participating countries, but not all institutions have access to guidelines or offer training facilities (Brazil, Chile, Costa Rica, Kenya). Where there is such access, the training offered is often not formal, standardized, systematic or compulsory. Sometimes elder abuse is included in more general training and work protocols (Brazil, Chile, Kenya, Spain). As a consequence, social workers use their professional experience and training from the area of domestic violence of women and children and then adapt it to their work with older people. In Singapore, many decisions concerning older people require the family’s consent. Front-line workers are therefore forced to judge situations from the perspective of the families. Furthermore, inter-professional coordination is considered to be the key to intervention but is often in need of improvement or lacking (Spain). The SWEF was in general regarded by the workshop participants as a very comprehensive and detailed assessment tool. Nevertheless, views about its applicability were mixed. The positive aspects outline the extensiveness of the form, covering many factors, questions and themes of which social workers needed to be aware. It could therefore serve as a good prompting tool and a resource for training purposes. The application of this evaluation form in most countries (Australia, Brazil, Costa Rica, Singapore, Spain, Switzerland) was considered to be infeasible. The length of the form imposed the main challenge, providing both practical and theoretical difficulties. Another key problem is the perception of the difficulty of getting honest answers to many of the questions: Some people minimize their problems in order to avoid trouble. In some countries, social workers’ schedules do not include regular home visits and it would therefore not be possible to verify a person’s situation at home. A very solid, trusting relationship would be necessary between the person administering the questionnaire and the interviewed person, but such a relationship can be built up only over a period of time. Some of the wording of the form and/or the style of the questions were considered limiting or inapplicable in some countries (Chile, Singapore, Spain, Switzerland). In addition, the participants expressed their reservations regarding the application of this form to cognitively impaired people. The problem of over-assessing people was raised, as there are already many assessment tools in use. It was also stressed that labels such as “abuse” and “neglect” are not often used by social workers. The goal of social work intervention was seen as improvement of an older person’s quality of life and not to accuse and label somebody as “abuser” or “victim”. Further doubts about the applicability of the form concerned intervention issues. How does the form relate to an intervention plan? A manual that accompanies the form to assess suspicion and a flowchart adapted to local intervention possibilities was considered to be necessary. The form was viewed as limiting and not providing ample space for the social workers conducting the assessment to explore further. Moreover, possibilities for intervention often depend on the existing legislation. Intervention orders, where they exist, are frequently difficult to enforce due to reluctance on the part of the victim to continually report the perpetrator (often somebody close), the general physical vulnerability of the older person and, sometimes, a lack of police understanding and/or capacity to deal with the situation. 48


为了使该表更有适用性,人们作出了以下的建议:

・该表在数次访问后,建立了信任之后可以使用。 ・对该表的使用,应当依据老人的具体状况因人而异。只应当使用那些和社工的怀疑相关的部分 (例如,财产虐待)。它的应用可以限制在特定的领域里,比如生活状况、家庭互动、任何家庭 成员的成瘾情况、老人的身体活动以及经济依赖性以及社会和情感孤立程度。

・对于一个需要危机管理/干预的情况比如老年人虐待,问题应当缩小范围,并且更集中于分析问 题的严重程度、历史以及虐待频繁程度。

・为了缩短该表,介绍部分可以被省略(到问题19为止),因为这部分信息有其它来源渠道,例如 病历。 除了该表之外,参与者认为还需要一系列的准备工作。预防措施应该到位,比如给予看护者更 好的援助,更多的专业人员参与处理这个问题,包括警察,以及社区/社会中的人对于老年人虐待及 其危害有更多的了解。老人应该可以得到24小时在线的支援渠道来举报虐待案件或者获得信息。建 议更多地利用现存的关于性虐待、故意伤害以及家庭暴力的法律,它们现在在老年人虐待领域还没 有被使用或者没有被充分使用。包含例如医生、社工和走访护士在内的跨行业的合作至关重要,并 且可以通过组织各个利益相关方,包括老年人在内的人组成圆桌协商会议来分享经验、传播信息以 及提供解决方案而增强这种合作。这些小组可以举办案件会议以及制定针对个人的策略方案,来保 护那些在家的有风险的老人,或者那些开始接受干预命令对抗虐待者的老人。这需要定期的家访支 持以便于更好地保护老人。

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the following suggestions were made in order to make the form more applicable: • The form could be used over a number of visits once trust is established. •  The use of the form should be individualized, depending on the particular circumstances of the older person. Only the parts that are relevant to the social worker’s suspicion (e.g. financial abuse) should be used Its application could be limited to specific areas such as living conditions, family dynamics, addictions of any family members, degree of physical and economic dependence of the older person and social and emotional isolation. •  For a crisis management/intervention situation such as elder abuse, the questions should be narrowed down and should focus more on analysing the seriousness, history and frequency of the abuse. • In order to shorten the form, the introductory part could be omitted (up to Question 19), since this information is available from other sources, for example from medical records . Apart from the form, the participants thought that a number of initiatives were needed. Preventive measures should be in place, such as better support for carers, more professionals dealing with the issue, including the police, and a greater awareness in the community of elder abuse and its devastating effects. Older people should have access to on-call 24-hour support to report abuse cases or to obtain information. Greater use of existing legislation relating to sexual abuse, assault and family violence, which is currently not used or not used sufficiently in elder abuse, is recommended. Interdisciplinary collaboration involving, for example, general practitioners, social workers and visiting nurses, is crucial and could be improved by organizing round tables for the different stakeholders, including the older people, to share experiences, disseminate information and offer solutions. The teams would hold case meetings and develop individual strategic plans to protect older people in their homes who were at risk or who had taken out intervention orders, where these exist, against an abuser. This would need to be accompanied by regular home visits in order to improve protection for older people.

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3.5 基层医疗护理人员与社工的研讨会 参与者不仅讨论了现存的评估方法以及可能的干预方案,也分别讨论了在不同国家会妨碍老年 人虐待的预防和侦测的障碍19。 两个专业人员小组(基层医疗护理人员和社工)都遇到过被虐待的病人,但是反应不尽相同。社 工们表现地更愿意牵涉进去,并且会互相分享彼此处理老年人虐待案例的经验。社工会访问被虐待 的当事人以及/或者寻找可行的合适的系统部门来援助。全科医生/基层医疗护理人员通常会将病人 转交给社工,如果他们有足够的信息,但是会更犹豫是否要积极行动并且常常感到无力。这种不情 愿可能是因为他们能给予每个病人的时间有限,缺少跟进策略或者感受到不同职业所被赋予的角色 期望以及责任不同。在其中一个环境下(新加坡),发现老年医生比年轻医生更适合处理老年人虐待。 一些有问题的方面被指出妨碍了预防和干预的效果。在所有国家,政策制订者对于基层医疗护 理人员的了解程度都有待提高。另一个问题涉及一些国家(哥斯达黎加、肯尼亚、新加坡)的法规没能 充分地覆盖老年人虐待问题。在巴西有法定的举报义务,但是担忧转移到了基层医疗护理人员身 上,他们会需要担心自身的安全。老年人虐待的评估中还会缺乏以下内容:(i)对老年人虐待问题的 培训,(ii)行业间的交流和协调,(iii)标准化的干预的规章,(iv)具体定义和术语,(v)对看护者的社会 援助以及(vi)关于公共机构资源的信息的流通。 为了提高基层医疗护理人员以及社工们处理老年人虐待的能力,提出了以下的建议行动:

・让政府提高对老年人虐待问题的敏感意识是一个重点。政府支持将会有利于招聘到基层医疗护 理人员,尤其是医生。

・全科医生有必要了解如何将病人转交给其他专业人员比如社工,以便于有嫌疑案例的管理。建 议给一线工作者建立一个持续的地方平台,以分享老年人虐待相关信息。

・不仅仅专业人员应该接受培训,整个社会也应该对此更敏感,老人们应该知晓他们的权利,尤 其是关于虐待、忽视和剥削的部分。

・有效的解决方案也需要包括针对施虐者的部分。 ・护士的角色需要被重新审视。在一些国家,护士可能具有更强的能力来处理老年人虐待问题。

19 在社工研讨会中已经提到的类似议题在这小节不再重复。

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3.5 Workshop with PHC professionals and social workers The participants discussed existing assessment and intervention possibilities but also the barriers that can hamper the prevention and detection of elder abuse in the respective countries. Both professional groups (PHC professionals and social workers) have encountered abused patients but reacted differently. The social workers appear more willing to get involved and would want to share with each other their experiences in handling and managing cases of elder abuse. Social workers either interview the abused client and/or find out about the available and appropriate systems of support. General practitioners/PHC professionals usually refer the patients to social workers, when they have the necessary information, but they are more hesitant to become active and often feel powerless. This reluctance may stem from the lack of time that they have with their patients, from the absence of follow-up strategies or from the expected role and responsibilities attached to each profession. In one setting (Singapore), it emerged that older GPs could relate better than younger physicians to elder abuse. Several problematic areas were pointed out that impede prevention and intervention efforts Policymakers’ awareness of PHC professionals needs to be increased in all countries. Another issue concerned the legislation in some countries (Costa Rica, Kenya, Singapore) that does not cover issues of elder abuse adequately. Brazil has mandatory reporting, but concerns were raised on behalf of the PHC professionals as they were worried about their own safety. Further difficulties in the assessment of elder abuse included a lack of (i) training on elder abuse, (ii) interprofessional communication and coordination, (iii) protocols for homogeneous interventions, (iv) specific definitions and terminologies, (v) social support for caregivers and (vi) circulation of information regarding the existing institutional resources. In order to develop PHC professionals’ and social workers’ capacities to deal with elder abuse, the following initiatives were suggested: •

Sensitizing governments about the issues of elder abuse is one of the priorities Governmental support would help in engaging PHC professionals, especially physicians.

General practitioners need to know how to refer patients to other professionals, such as social workers, for the management of suspected cases. The establishment of a local continuing platform where front-line workers can share information related to elder abuse is recommended

Not only should professionals receive training, but also the community should be sensitized and older people should be informed about their rights, in particular in relation to abuse, neglect and exploitation.

Effective solutions need to include the perpetrator of abuse.

The role of nurses needs to be reviewed In some countries, nurses may have more capacity than physicians to deal with elder abuse.

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有人认为为专业人员编写一本具有老年人虐待的基本信息的手册以便于处理该问题是必要的。 参与者分别讨论了PAHO(泛美医疗组织)手册 20和它在不同国家的应用性。参与者一致认为以下一些 要点应该被修改或者增补21: 1.

老年人虐待的定义 a.

性虐待、遗弃、忽视和自我忽视应该在不同的分类中。

b.

身体虐待应该包括“强迫性药物治疗或干预”

c.

情感虐待可以从心理虐待中分离出来。情感虐待更关注对受害者造成的结果,比如焦虑、 沮丧、悲伤和孤独;心理虐待也包括“限制个人能接触到的资源”。

d.

可以增加以下的分类: i. ii.

遗弃和寄养; 家庭与性别暴力,例如在晚年对女性的持续暴力;

iii.

家庭成员在老人不希望或者没有必要的情况下代替老年人作决定;

iv.

财产动机与家庭贪婪;

v.

利用老人对虐待、忽视、孤立或遗弃的恐惧来控制老人。

vi.

风险指标是通过基于个人权利的方法描述的。这可能不适用于相对个人权利更强调家 族权利的社会,比如新加坡。

20 与这里讨论的内容相关的手册部分可以在附录3中找到。 21 开头数字指代PAHO手册的具体章节。

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It was considered that a manual with basic information on elder abuse for professionals dealing with the issue was necessary. Participants discussed the usefulness of the PAHO manual and its applicability in their respective countries. Participants agreed that the following points should be modified or added.

1.

Definition of elder abuse a. b. c.

d.

Sexual abuse, abandonment, neglect and self-neglect should be separate categories. Physical abuse should include “forced medical treatments or intervention”. Emotional abuse could be separated from psychological abuse. Emotional abuse focuses more on the outcomes for the victim, such as anxiety, depression, sadness and loneliness; psychological abuse also includes “limiting the resources of a person”. The following categories could be added: i. Abandonment and institutionalization; ii. Family and gendered violence, e.g. continuation of violence against women in later life; iii. Decision-making by family members on behalf of the older person when this is not desired by the older person or is not necessary; iv. Financial motivation and family greed; v. Using fear of abuse, neglect, isolation or abandonment to control the older person. vi. The risk indicators are portrayed as an individual rights-based approach. This may not be suitable for societies that place more emphasis on familial rights than on individual rights, such as Singapore.

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2.

诊断的原则 a.

在“家庭中的风险因素”中,有人提议缺少了一组主要因素,即各种老年人的弱点,比如 身体缺陷、疾病或者身体衰弱、高护理需求以及痴呆(或者其他行为问题可能诱发虐待)。 另一个方面是看护者的行为缺陷(例如缺乏责任感以及贪婪),长期矛盾关系的历史以及施 虐者和/或受害者的精神疾病/人格障碍。

b.

在“社会公共机构和社区之家中的风险因素”中,对病人的全员广播、过度拥挤以及缺乏 社区及社会交流也可能有关联。

c.

全科医生并不一定在所有国家都是老年人虐待案件中的“第一避风港”,因为他们缺乏时 间和培训,例如在澳大利亚。因此,在图表1.1中的建议方法需要根据环境调整。

d.

手册中假定老年人遭受虐待会有身体症状,但通常未必如此。

e.

医生并不一定熟悉病人的历史,因为一些病人频繁地更换治疗医生而且同一位医生未必总 是有时间看一位特定的病人。

f.

手册中假定老人与家庭成员/看护者的冲突一定会留下证据,但通常紧张关系会被巧妙地隐 藏或者否定。

g.

其中没有提到文化差异或者可能需要的翻译人员的在场。

h.

其中没有程序规定医生必须在接触或者为老年病人做身体检查前征得同意,而这在防范性 侵犯中尤其重要。

i.

风险指标被认为是一个有用的清单,但对于医生来说只是足以称作一个“诊断指导”,因 为指标不够具体。大家更倾向于有一张可以在评估最后核对使用的一览表。

j.

全科医生以及社工推荐在表格1.2中采用社会医疗诊断。

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2.

Basis of the diagnostic a.

b. c.

d. e.

f. g. h. i.

j.

Under “Risk factors in the family”, it was suggested that one main set of missing factors were various types of vulnerability in the older person such as disability, illness or frailty, high care needs and dementia (or other behavioural issues that could trigger abuse). Another area was failings in caregiver behaviour (e.g. lack of responsibility and greed), history of long-term conflicted relationships and mental illness/personality disorders in the perpetrator and/or the victim. Under “Risk factors in institutions and community homes”, staff-to-patient ratios, overcrowding and lack of community and social interactions might also apply. General practitioners are not the “first port of call” in all countries for issues of elder abuse, due to their lack of time and training, e.g. Australia Therefore, the suggested approach in Diagram 1.1 needs context-specific adaptation. It is assumed in the manual that the older person will have physical symptoms of abuse, which is often not the case. A physician is not necessarily familiar with the patient’s history, since some patients change their doctors with a high frequency and the same doctor may not always be available to see an individual. It is implied that conflicts with a family member/caregiver is evident, but stressful relationships are often well hidden or denied. There is no mention of cultural differences or likely needs for translators or interpreters to be present. There is no procedure whereby physicians must ask consent before touching or physically examining older patients; this is especially important in cases of sexual assault. The risk indicators are considered as a useful list, but for physicians it would be adequate to call it a “diagnostic guide”, as the indicators were not specific enough Greater preference was given for a checklist that could be used at the end of the assessment. General practitioners and social workers recommend an adoption of a sociomedical diagnosis in Table 1.2.

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3.

治疗的原则 a.

流程图中的方法过于医学化处理了。使用“治疗”这个词使得老年人虐待听上去像是一种 疾病。关注焦点应该在于消除或者减轻施虐者对于老人造成的伤害。

b.

在一些国家“成年人保护服务”以及强制性举报措施并不存在;同样也包括具体的干预命令。

c.

转送选择权在不同国家间各有差异,需要针对具体环境作改写。

d.

针对施虐者进行改造和教育似乎往往比只针对老年人的教育来得更合适。

e.

术语“干预”可以用“提供选择”或者“援助”来替代,因为干预似乎意味着免除了老人 的委托权力。

f.

图表1.3中没有适当处理一个重要的问题,那就是确保受害者安全的需要,并针对个人开展 适当的安全保护计划,尤其是对于那些没有能力决定是否接受服务的病人。

g.

4.

作为干预计划,建议创立一条基层医疗护理人员的热线。图表1.3被认为有些不够灵活。

推荐阅读文献 a.

文献列表需要更新。

参与者总结认为PAHO手册不适合于在新加坡、西班牙以及澳大利亚使用,基于以上列出的原 因22 。在这三个国家,已经有了似乎更能反映国家具体现实的跟进策略。巴西小组认为手册可以被 应用,因为它可以提升基层医疗护理人员对虐待和忽视的了解,如果它更短并且根据巴西环境做调 整,例如流程图需要一些改动。在哥斯达黎加和肯尼亚,人们强烈地感到PAHO手册的内容和问题 很合适并且可以立即应用。

22 这部分概括的对PAHO手册建议大部分是基于这三个国家的报告。

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3.

Basis for treatment a.

b. c. d. e. f.

g.

4.

The approach of the flowchart is too medicalized. Using the word “treatment” makes elder abuse sound like a disease. The focus should be on removing or lessening the harm caused to the older person by the perpetrators of abuse. In some countries “adult protective services” and mandatory reporting do not exist; nor are there specific intervention orders. Referral options vary from country to country and need to be adapted accordingly within specific contexts. A focus on the rehabilitation and education of the perpetrator often seems to be more appropriate than strategies being directed only at the education of the older person. The term “intervention” can be replaced by “options” or “assistance”, as an intervention may seem to remove the agency from the older person. An important issue that was not addressed appropriately in Diagram 1.3 is the need to ensure the victim’s safety and that appropriate safety planning takes place for individuals, particularly for patients who do not have the capacity to decide for themselves about accepting services. As for an intervention plan, it was suggested to create a hotline/helpline for PHC professionals The diagram (1.3) was viewed as slightly inflexible.

Suggested reading a.

The literature list needs to be updated.

The participants concluded that the PAHO manual was not considered appropriate for use in Singapore, Spain or Australia for the reasons outlined above. In these three countries, follow-up strategies are already in place that seem to better reflect the country-specific realities. The Brazilian group thought that the manual would be used if it was shorter and adjusted to the Brazilian context – for instance, the flow- charts need some adaptation – as it could raise awareness about abuse and neglect among PHC professionals. In both Costa Rica and Kenya, there was a strong feeling that the PAHO manual’s content and issues are appropriate and it could be used readily.

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4 建议与结论 贯穿项目的执行过程,WHO和CIG为了寻找鉴别和可能预防老年人虐待的方案在参与国家范围 内使用了跨行业以及跨机构的方法。研究的复杂性——在全球层面处理一个高度敏感的话题并且考 虑文化差异——显示了要响应马德里国际应对老龄化计划而发展合适的老年人虐待鉴别策略需要许 多步骤。特别地,要吸收三个主要利益相关方:老年人、医生以及社工的观点至关重要。 在不同国家所作的专题小组与研讨会讨论的结论证实了蒙特利尔EASI研究的发现和建议:

・一个工具有12个问题显得太长了,考虑到在大多数参与国家中全科医生一般的问诊时间只有 10-15分钟甚至更少。一个更简短的覆盖老年人虐待所有重要方面的工具才有更大的机会被基 层医疗护理人员所接受与应用。

・在应用问卷之前,判断病人是否有明显的认知障碍迹象是非常重要的。 ・这些问题应当在病人单独一人时提问。 ・一位老年病人与一位了解他的医生保有持续的紧密的关系已经变得越来越不可能。因此要应用 问卷应当需要一位基层医疗护理人员数次访问以便于在病人与医疗护理人员之间建立足够的信 任关系。

・当侦测到可疑的老年人虐待,有必要为基层医疗护理人员配备跟进机制/转送策略。 其他还提到的要点包括:

・护士可以成为医生的重要的替代者来应用这套问卷。 ・一个对该工具中概念的主要挑战来源于专题小组讨论。一些问题(例如问题11)显得有些含糊不 清,因为不清楚一个人是被故意伤害还是意外受伤。看护者可能需要关于合适的提举与搀扶老 人的训练以避免将来对老人造成伤害。

・参与者指出的另一个难点在于一些人可能难以回答这些问题。 ・对老人的暴力威胁以及伴随的恐吓是一个在12个问题中没有涉及的重要问题。

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4 Recommendations and conclusions Throughout the execution of this project, WHO and CIG embraced an interdisciplinary and interagency approach with the objective of pursuing identification and prevention possibilities for elder abuse in the range of participating countries. The complexity of the research – tackling a highly sensitive topic at a global level and taking into account cultural differences – has shown that multiple steps are necessary to develop appropriate elder abuse identification strategies in response to the call from the Madrid International Plan of Action on Ageing. In particular, it is crucial to include the views of the three main stakeholders: older people, medical doctors and social workers. The conclusions from the focus group and workshop discussions in the various countries corroborate the findings and recommendations from the EASI study in Montreal: •

An instrument with 12 questions is too long, considering that in most of the participating countries the standard consultation time of a general practitioner is 10-15 minutes or less. A shorter instrument covering all key dimensions of elder abuse has a higher chance of being accepted and applied by PHC professionals.

Before applying such a questionnaire, it is crucial to determine whether the patient shows significant signs of cognitive deterioration.

These questions should be asked only when the patient is seen alone.

It is becoming less likely that an older patient has a consistent and close relationship with a physician who knows the patient well The questions should therefore be applied by a PHC professional over a few visits in order to establish a sufficient trusting relationship between the patient and the PHC professional.

In case elder abuse is suspected, it is essential to equip PHC professionals with follow-up mechanisms/referral strategies.

Further points mentioned were:

Nurses could be important alternatives to physicians in applying such a questionnaire.

A major challenge of the concept of such a tool arose in the focus group discussions. Some of the questions (e.g. Question 11) are somewhat ambiguous, as it is not clear whether a person was hurt accidentally or unintentionally. A caregiver may need training about appropriate lifting and handling an older person in order to prevent harm or injury occurring in future

Another difficulty pointed out by the participants is that some people may find it hard to answer these questions.

The threat of violence and associated intimidation to an older person is an important issue that is not addressed in the bank of 12 questions.

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对于老年人专题小组、基层医疗护理人员专题小组,以及来自不同国家的小组,试图得到比较 完整的、精确的结论,是一件比较难以达成的事情,由于专题小组的性质以及参与者人数有些巨大 差异。不过还是得到了以下一些结论:

・在一些国家,比如新加坡,老年人和基层医疗护理人员在问卷中几乎选择了同样的保留问题, 但是在其他国家选择有很大不同。

・在所有相关的老年人专题小组,问题4和问题5被选为最重要的,接下来是问题6、8和11(在国 家间有较少的一致性)。而基层医疗护理人员的选择更统一:首选基本都是问题4、5、6、11和 12。

・一定数量的相似的观点同时出现在两类小组中(老年人以及基层医疗护理人员): ・医生和病人之间的信任关系是很重要的。 ・大多数老年人在寻求帮助时会感到不适。 ・尽管大家普遍一致认为问卷需要缩短、措词需要简化,但是对于问题的长度没有形成共识。一 方面,一些人认为长问题会难以理解但是可以减少问题数量。另一方面,短问题可能更易于理 解但是会使得问卷更长,问题数量越大——即使每个问题更短——老年人注意力越容易涣散。

・一些问题的重要性,比如那些关于酒精问题以及经济依赖的问题,取决于地理文化环境。 ・关于性虐待的问题引发了最大的分歧。大多数老年人认为这个问题过于微妙或者不够相关,然 而基层医疗护理人员认为这个问题有必要被包括进去。

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An entirely accurate comparison of the results from the focus groups with older people and PHC professionals – and additionally across the countries – is difficult to achieve, since the nature of the focus groups conducted and the number of participants varied significantly. The following conclusions can be drawn, however: •

In some countries, such as Singapore, older people and PHC professionals both chose an almost identical set of questions to be retained in the questionnaire, but in other countries the selection differs widely

In all the relevant focus groups with older people, Questions 4 and 5 were chosen as the most important, followed by Questions 6, 8 and 11 (with lesser consistency across the countries). The choices made by the PHC professionals were more uniform: Preferences were given mostly to Questions 4, 5, 8, 11 and 12.

A number of similar points were brought up in both groups (older people and the PHC professionals):

A trusting relationship between the physician and the patient is important.

Most older people feel uncomfortable when asking for help.

Although there was a general agreement that the questionnaire needs to be shortened and the wording simplified, there was no consensus on the length of the questions. On the one hand, some thought that longer questions were more difficult to understand but allow for fewer questions. On the other hand, shorter questions might be more comprehensible but would lead to a longer questionnaire; the more extensive the questionnaire – even if the questions are shorter – the higher the chance of losing the attention of older people.

The importance of some questions, such as those pertaining to alcohol problems and economic dependence, depends on the geographical and cultural context.

The question on sexual abuse sparked the biggest controversy. Most older people considered this question too delicate or not relevant enough, whereas PHC professionals thought that it was necessary to include this question.

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这次项目的主要目的是探究开发一个可以应用于不同文化地理环境中提高基层医疗护理人员对 老年人虐待与忽视的了解程度的工具的可行性。 结果显示不是所有问题都是对各文化有效的——例如关于性虐待的问题——并且可以在所有环 境下询问。需要找到更微妙的方法来处理这个问题。结果也揭示了基层医疗护理人员和老年人们认 为合适的问题间的不一致。基于这项研究的结果,我们还不能将这项工具推荐到全世界范围应用, 因为它不能在所有情况下符合文化敏感性。然而有可能开发一种在核心问题上足够灵活的工具,使 得它改写起来相对容易以应用于不同的地理文化环境。 尽管如此,涉及一种针对隐藏的并且广泛的老年人虐待社会现象的策略是重要的。老年人虐待 嫌疑指标以及其他评估技术——比如一套合适的社会工作评估和一本依据各种地方环境改编的包含 预防、鉴别和干预方法的手册——是未来努力方向的重要起点。我们建议这样的开创性工作在全世 界每个国家开展起来。这些开创性工作应当和那些为了预防虐待和保护有需要的老人所作的努力相 辅相成,以便于解决这样一个影响着成千上万老年公民生活的问题。

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The main goal of this project was to investigate the feasibility of developing an instrument applicable in different cultural and geographical contexts that could raise PHC professionals’ awareness about elder abuse and neglect. The results show that not all questions are culturally sensitive – for example, the question on sexual abuse – and cannot be asked in all settings. More subtle ways have to be found to address this issue. The results also revealed some discrepancies between the set of questions regarded as suitable by PHC professionals and by older people. Based on the results of this study, we cannot yet recommend the tool to be universally applicable because it cannot conform to cultural sensitivities in all settings. It might be possible, however, to develop a tool that is sufficiently flexible in the core questions used that it could be adapted relatively easily for use in different geographical and cultural contexts. Nevertheless, it is important to devise a strategy for the hidden and widespread societal phenomenon of elder abuse. The Elder Abuse Suspicion Index together with other assessment techniques – such as an appropriate social work assessment and a manual containing information on prevention, identification and intervention approaches tailored to a variety of local contexts – are important starting points from where future efforts can proceed. We recommend that such initiatives should be developed in all countries across the world. These initiatives should complement efforts aimed at the prevention of abuse and at protecting older people in need in order to address a problem that impacts thousands of older citizens’ lives.

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5 参考文献 Acierno R et al. Assessing elder victimization: demonstration of a methodology. Social Psychiatry and Psychiatric Epidemiology, 2003, 38:644-653. Ahmad M, Lach MS. Elder abuse and neglect: what physicians can and should do. Cleverland Clinic Journal of Medicine, 2002, 69:801-808. Baker A A. Granny-battering. Modern Geriatrics, 1975, 5:20-24. Ewing JA. Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association, 1984, 252:1905-1907. Hudelson PM. Qualitative research for health programmes. Geneva, World Health Organization, 1994. Jiménez Rodríguez S. Las Personas Mayores y el Abuso: estudio realizado en el Hospital Nacional de Geriatría Dr. Blanco Cervantes. San José, Costa Rica, 1998. Lachs MS. Screening for family violence: what’s an evidence-based doctor to do? Annuls of Internal Medicine, 2004, 140:399-400. Moya A, Gutiérrez BJ. Malos Tratos a personas mayores, Guía de actuación. Madrid, IMSERSO/ SEGG, 2005. Machado L et al. Paper presented at the XVI World Congress on Gerontology, Adelaide, Australia. 1997. National Research Council. Elder mistreatment: abuse, neglect, and exploitation in an aging America. Panel to review risk and prevalence of elder abuse and neglect. Washington, DC, The national Academies Press, 2003. Pan American Health Organization. Guía Clínica para atención primaria a las personas adultas mayors. Washington, DC, Pan American Health Organization, 2002. Pillemer K, Finkelhor D. The prevalence of elder abuse: a random sample survey. Gerontologist, 1988, 28:51-57. Rosenblatt DE, Cho KH, Durance PW. Reporting mistreatment of older adults: the role of physicians. Journal of the American Geriatrics Society, 1996, 44:65-70. Ruiz Sanmartin A et al. Violencia doméstica: prevalencia de sospecha de maltrato a ancianos. Atención Primaria, 2001, 27:331-334 Souza ER et al. La morbilidad hospitalaria por violencia contra ancianos: estudio de la atención de emergencia em dos hospitales públicos de Rio de Janeiro. Cuadernos Médico Socialies, 1999, 76:71-82. 65


Souza ER et al. Extremo da vida sob a mira de violencia: mortalidade de idosos no Estado do Rio de Janeiro. Gerontologia, 1998, 6:66-73. United Nations. Madrid International Plan of Action on Ageing, 2002. New York, NY, United Nations Department of Economic and Social Affairs, 2002 (http://www.un.org/esa/socdev/ageing/ waa/a-conf-197-9b.htm), access date: July 2006. World Health Organization/INPEA. The Toronto declaration for the global prevention of elder abuse. Geneva, World Health Organization, 2002b. Yaffe MJ, Lithwick M, Wolfson C. A North American view on elder abuse. Presented at World Health Organization Symposium: WHO Approaches to the Prevention of Elder Abuse, 18th Congress of the International Association of Gerontology. Rio de Janeiro, Brazil, 26-39 June 2005. Yan E, Tang CSK. Prevalence and psychological impact of Chinese elder abuse. Journal of Interpersonal Violence, 2001, 16:1158-1174.

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6 项目组 项目协调员 WHO: Alexandre Kalache, Head Ageing and Life Course programme, WHO, Family and Community Health, Geneva, Switzerland

CIG-UNIGE/HUG: Chales-Henri Rapin, Directeur adjoint, Centre Interfacultarie de Gérontologie de l’Université de Genève (CIG-UNIGE) and Médecin chef de service, Programme “Bien Vieillir” des HUG. Geneva Switzerland

CIG-UNIGE/WHO: Karina Kaindl, Centre Interfacultarie de Gérontologie de l’Université de Genève (CIG-UNIGE) and Ageing and Life Course programme, WHO, Family and Community Health, Geneva, Switzerland

Silvia Perel Levin和Maria Casares都曾是项目协调组的一部分,但是在2004年12月离开了小组。

研究合作者与专家 Mark S.Lachs, Professor of Medicine, Division of Geriatrics and Gerontology, Weill Medical College of Cornell University, New York, NY, United States of America

Maxine Lithwick, Researcher and Social Worker, Centre de santé et de services sociaux de RenéCassin et Notre-Dame-de-Grace/Montréal-Ouest, Montréal, Canada

Mark J. Yaffe, Professor of Family Medicine and Chief, Department of Family Medicine, McGill University, St Mary’s Hospital, Montreal, Canada

合作与试点中心/各国研究的国家协调员 澳大利亚:

Gordana Martin, Department for Victorian Communities, Officer of Senior Victorians, Melbourne, Australia 67


巴西:

Laura Machado, InterAge Consulting in Gerontology, Rio de Janeiro, Brazil 智利:

Pedro Paulo Martin, Catholic University of Chile, WHO Collaborating Centre on Ageing and Health, Santiago, Chile 哥斯达黎加:

Fernando Morales-Martinez, Hospital Nacional de Geriatría y Gerontología Dr Raul Blanco Cervantes, Calles 18-10, Avenida 8, San Jose, Costa Rica 肯尼亚:

Ms Amleset Tewodros, HelpAge International, Africa Regional Development Centre, Regional Representative – Africa, Nairobi, Kenya 新加坡:

Susana Concordo, Tsao Foundation, Singapore 西班牙:

Mayte Sancho Castiello and Antonio Yuste, Ministry of Social Welfare and Labour/Sociedad Española de Geriatria y Gerontología (IMSERSO/SEGG), Madrid, Spain 瑞士:

Charles-Henri Rapin, Hôspital de Loëx, Bernex/Geneva, Switzerland

报告评估员 Terezinha Da Silva, Adviser and Trainer, Legal and Judiciary Training Centre, Maputo, Mozambique Bridget Penhale, Senior Lecturer, University of Sheffield, Sheffield, United Kingdom of Great Britain and Northern Ireland

校对 Govind Rangrass, Yale University, Newhaven, CT, United States of America 68


附录1:专题小组研究计划 嫌疑指标包含的12个问题: 问题1 你经常感到孤独吗? ☐ 是

☐ 否

☐ 没有回答

我们只有大约5-10分钟的时间来讨论每个问题;以下是我们希望你思考的内容:

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题2

问题2 当你需要帮助时,向他人求助是否会让你感到不自在? ☐ 是

☐ 否

☐ 没有回答

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题3

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Annex 1: Focus groups research protocol Twelve questions for a suspicion index: Question 1 Do you usually feel lonely? ☐ Yes ☐ No ☐ Did not answer

We only have about 5–10 minutes for each question; here is what we would like your thoughts on: •

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 2

Question 1 When you need help, do you feel uncomfortable turning to people for help? ☐ Yes ☐ No ☐ Did not answer

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 3

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问题3 你的大部分日常生活需求是否需要依赖他人的帮助? ☐ 是

☐ 否

☐ 没有回答

如果是:你和这个人会常常产生争论吗? ☐ 是

☐ 否

☐ 没有回答

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题4

问题4 有没有谁曾阻止你拥有需要的东西,比如食物、药品、衣服、充足的生活空间,或者健康辅助器 比如眼镜、助听器等等? ☐ 是

☐ 否

☐ 没有回答

如果是:这是一次孤立的事件还是不止发生过一次? ☐ 只有一次 ☐ 超过一次

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题5

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Question 3 Do you depend most of the time on someone for help with your basic daily needs? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Are disagreements common between such people and yourself? ☐ Yes ☐ No ☐ Did not answer

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 4

Question 4 Has anyone prevented you from having needed things such as food, medication, clothing, adequate living space, or health aids such as eyeglasses, hearing aids, etc ? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Was this an isolated event or has it occurred more than once? ☐ Isolated ☐ More than Once

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 5

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问题5 有没有哪位你亲近的人曾无缘无故对你大喊大叫,或者用你不喜欢的方式与你说话,或者让你觉 得特别难过、羞愧、害怕、焦虑或者不高兴——因此让你难受很长一段时间? ☐ 是

☐ 否

☐ 没有回答

如果是:这是一次孤立的事件还是不止发生过一次? ☐ 只有一次 ☐ 超过一次

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题6

问题6 有没有哪位与你亲近的人曾让你觉得被占便宜,或者阻止你做对你自己很重要的事情,或者干预 你和要好的同伴呆在一起? ☐ 是

☐ 否

☐ 没有回答

如果是:这是一次孤立的事件还是不止发生过一次? ☐ 只有一次 ☐ 超过一次

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题7

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Question 5 Has anyone close to you unfairly yelled at you, or talked to you in ways that you did not like, or made you feel especially sad, shamed, fearful, anxious, or unhappy – in a way that left you upset for a long time? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Was this an isolated event or has it occurred more than once? ☐ Isolated ☐ More than Once

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 6

Question 6 Has anyone close to you made you feel that you were being taken advantage of, or prevented you from doing things that were important for your well being, or interfered with you being with the people you wanted to be with? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Was this an isolated event or has it occurred more than once? ☐ Isolated ☐ More than Once

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 7 74


问题7 有没有谁在经济上需要依赖你? ☐ 是

☐ 否

☐ 没有回答

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题8

问题8 有没有哪位你曾信任的人用你不想要的方式使用或者试图使用你的钱、财产或房产,或者强迫你 签署你并不理解或者不想要签署的文件? ☐ 是

☐ 否

☐ 没有回答

如果是:这是一次孤立的事件还是不止发生过一次? ☐ 只有一次 ☐ 超过一次

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题9

75


Question 7 Do you have anyone who is financially dependent on you? ☐ Yes ☐ No ☐ Did not answer

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 8

Question 8 Has anyone that you would trust used or tried to use your money, possessions or property in ways that you did not want, or forced you to sign documents that you did not understand or did not want to sign? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Was this an isolated event or has it occurred more than once? ☐ Isolated ☐ More than Once

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 9

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问题9 你是否和某位你认为喝酒喝得太多的人居住在一起? ☐ 是

☐ 否

☐ 没有回答

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・ 这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题10

问题10 你是否和某位有过精神病史的人居住在一起? ☐ 是

☐ 否

☐ 没有回答

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题11

77


Question 9 Do you live with anyone who drinks alcohol more than you think he/she should? ☐ Yes ☐ No ☐ Did not answer

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 10

Question 10 Do you live with anyone who has a history of mental illness? ☐ Yes ☐ No ☐ Did not answer

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 11

78


问题11 有没有谁曾伤害你的身体,例如击打你、推你或者限制你的活动自由? ☐ 是

☐ 否

☐ 没有回答

如果是:这是一次孤立的事件还是不止发生过一次? ☐ 只有一次

☐ 超过一次

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗? 你现在可以往下翻到问题12

问题12 有没有谁曾用你不想要的方式触碰你,或者在你不情愿的情况下作性接触,以至于让你感到难 受? ☐ 是

☐ 否

☐ 没有回答

如果是:这是一次孤立的事件还是不止发生过一次? ☐ 只有一次

☐ 超过一次

・这个问题对于侦测老年人虐待有多少重要性? ・你觉得这个问题的措辞如何?其中有什么用词会造成麻烦吗?它们可以用什么词语来替换? ・这个问题有没有冗余的部分? ・你认为一个问题包含数个论点是否会过于复杂或者难以回答吗? ・措辞是否显得太长,有什么改进的方法吗?

79


Question 11 Has anyone that you would trust used or tried to use your money, possessions or property in ways that you did not want, or forced you to sign documents that you did not understand or did not want to sign? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Was this an isolated event or has it occurred more than once? ☐ Isolated ☐ More than Once

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

You may now turn the page to Question 12

Question 12 To a degree that it upsets you, has anyone touched you in ways you did not like, or made unwanted sexual approaches? ☐ Yes ☐ No ☐ Did not answer If “Yes”: Was this an isolated event or has it occurred more than once? ☐ Isolated ☐ More than Once

How important is this item in detecting elder abuse?

How do you like the wording of the question? Are there any words that cause problems? What could they be replaced with?

Is there redundancy within the question?

Do you think having several issues in one question is too complicated or problematic in any way?

Is the wording too long – how might it be rephrased?

80


如果这项工具——老年人虐待嫌疑指标——只能包含5个问题,你会使用哪5个?请在问题所在 页圈出这5个问题题号。 请注意: 以上使用的问题大多数来自蒙特利尔Centre de santé et de services sociaux de RenéCassin et Notre-Dame-de-Grace (曾经是CLSC René Cassin), McGill University 和 St. Mary’s Hospotal的一项研究项目,由Canadian Institutes of Health Research资助。知识产 权属于以下研究员Mark J. Yaffe MD, Maxine Lithwick MSW, Christina Wolfson PhD和 Elizabeth Podnieks RN.

81


Suppose the instrument - the Elder Abuse Suspicion Index - could have only five questions which five would you use? Please circle the five question numbers on the pages with the questions. Please note: The questions used above were mostly derived from a research project of the Centre de santé et de services sociaux de René-Cassin et Notre-Dame-de-Grace (formerly CLSC René Cassin), McGill University, and St. Mary's Hospital in Montreal, funded by the Canadian Institutes of Health Research The intellectual property rights for them rest with the researchers Mark J. Yaffe MD, Maxine Lithwick MSW, Christina Wolfson PhD, and Elizabeth Podnieks RN.

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附录2:社会工作评估表 评估表

对象编号:

访谈地点:

评价者:

家中 ☐

其他:

转送接收时期(年/月/日): 首次访问时期(年/月/日): 第二次访问日期(如果有)(年/月/日): 对象已退出研究:

是☐

否☐

退出时间(年/月/日): 退出原因:

83


Annex 2: Social work evaluation form Evaluation Form Subject No.

Location of interview:

Evaluator:

Home ☐

Other:

Date Referral Received (yy/mm/dd): Date of first visit (yy/mm/dd): Date of second visit (if necessary) (yy/mm/dd): Subject withdrew from study: Yes ☐

No ☐

Date of withdrawal (yy/mm/dd): Reason for withdrawal:

84


第1部分:社会履历:(职业、婚姻、离婚、灾祸、不幸、教育、移民、搬迁、其他主要事件) 在这部分中,请对象讲述他的个人历史。在这过程中,收集以上提到的信息并且填写在下面: 1. 性别: 男 ☐ 或 女 ☐ 2. 年龄: 3. 访谈中使用的语言: 4. 工作 1. 已退休

工作类型?

2. 失业

从哪里?

3. 因身体原因无法工作 4. 全职工作担任: 5. 兼职工作担任: 6. 持家 7. 其他: 5. 住房 1. 家/公寓 ☐ 2. 经济适用房/廉租房 ☐ 3. 公共住房/长期护理设施 ☐ 4. 暂住地 ☐ ・ 带有服务 ☐ ・ 不带有服务 ☐ 5. 其他,请具体说明: 对象有没有指出关于住房状况(卫生、空间、安全、满意度……)的任何困难或者具体问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

85


SECTION 1: SOCIAL HISTORY: (occupation, marriage, divorce, grief, misfortune, education, immigration, moves, other major events. ) In this section, ask subject to tell you a personal history During this process, gather information on the above and fill it in below: 1. Sex:

M☐

or

F☐

2. Age: 3. Language used during the interview: 4. Occupation status (circle all that apply) 1. Retired

Type of work?

2. Unemployed

From what?

3. Unable to work for medical reasons 4. Employed full time as: 5. Employed part-time as: 6. Homemaker 7. Other: 5. Housing 1. Home/apartment ☐ 2.  Low cost housing/HLM ☐ 3.  Public housing/LTCF ☐ 4.  Residence ☐ •  Services ☐ •  No services ☐ 5. Other, please specify: • Are there any difficulties or specific problems that the subject has identified re: housing conditions (salubrity, space, security, satisfaction...)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

86


6. 出生国家: 如果适用,你现在是否在被资助? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,你与资助人是什么关系? 如果对象是来自其他国家,询问任何可能影响他来这个国家的具体原因(例如大屠杀、战争等等):

7. 婚姻状态 1. 已婚 ☐ 2. 丧偶 ☐ 3. 分居或离婚 ☐ 4. 单身 ☐ 5. 事实婚姻 ☐ › 异性伴侣 ☐ › 同性伴侣 ☐ 6. 亲密关系 ☐ 8. 居住安排 在所有符合的选项上打勾: 1. 独身 ☐ 2. 同配偶一起 ☐ 3. 同事实婚姻伴侣一起 ☐ 4. 同室友一起 ☐ 5. 同子女一起 ☐

几个?

6. 同孙子孙女一起 ☐ 几个? 7. 同其他亲戚一起 ☐ 8. 同支付工资的看护者一起 ☐ 87


6. Country of birth: If applicable, are you under sponsorship at this time? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", what is your relationship to the sponsor? If the subject is originally from another country, ask questions about any specific events that may have influenced their coming to this country (for example holocaust, war etc):

7. Marital Status 1. Married ☐ 2.  Widowed ☐ 3.  Separated or divorced ☐ 4.  Single ☐ 5.  Common law ☐ • different-sex partner ☐ • same-sex partner ☐ 6. Significant relationship ☐ 8. Living Arrangements Check all that apply: 1.  Alone ☐ 2.  With spouse ☐ 3.  With common law partner ☐ 4.  With roommate ☐ 5.  With child(ren) ☐

How many?

6. With grandchild(ren) ☐ How many? 7.  With other relatives: 8.  With paid caregiver ☐

88


9. 其他: ・ 你现在的居住安排已经持续了多久? ・ 这样的安排会造成问题吗 (例如:家庭矛盾,需要更多帮助,其他)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

9. 请描述过去12个月中经历的重要生命事件:(圈出所有符合的选项) 1. 无 2. 死亡 3. 离婚(自己或者家庭成员) / 和伴侣分居 4. 对象或者其共同居住者身体恶化 5. 经济地位的改变 6. 子女或者孙子孙女的迁入或迁出等等 7. 搬进或者搬离子女或者其他亲戚的家 8. 其他,请具体说明:

解释:

89


9. Other: • How long have you been in the present arrangement? • Is it problematic (for example: family problem, needs more help, other)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

9. Describe major life events in the last 12 months: (circle all that apply) 1. None 2. Death 3. Divorce (own or within family) / separation from partner 4. Physical deterioration of subject or the person with whom they live 5. Change in financial status 6. Child or grandchild moving in or out etc 7. Moving in or out of child's or other relative's home 8. Other, specify:

Explain:

90


第2部分:家庭动态 与配偶/伴侣的关系 10. 如果已婚,这是第一次婚姻吗?(如果这是事实婚姻或者长期同居关系,也一样适用该问 题。) 1. 是 ☐ 多久? 2. 否 ☐ 现在的关系有多久? 3. 不适用 ☐ (跳转到第12题) 4. 拒绝回答 ☐

11. 许多夫妻承认他们的关系中会时不时发生问题。你认为你们之间发生问题的频繁程度如何, 无论你如何定义所谓的问题,在以下选项中选择: 从不 ☐ 偶尔 ☐ 经常 ☐ 非常频繁 ☐ 说明:

・ 你的配偶或者伴侣有任何确切的健康问题或者情绪问题吗(包括疾病,残疾,酒精、毒品或赌 博成瘾,或者精神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 说明:

如果是,请描述这对你造成的影响:

91


SECTION 1: FAMILY DYNAMICS RELATIONSHIP WITH SPOUSE/PARTNER 10. If married, is this a first marriage? (Apply same questioning if it is a common law commitment or long-term relationship.) 1.Yes ☐

How long?

2. No ☐

How long in current relationship?

3. Not applicable ☐ (Go to question 12) 4. R/A ☐

11. Most couples acknowledge that there are, from time to time, problems that arise in their relationship. How often would you rate problems in yours, whatever your definition of problem is, using the following: Never ☐ Occasional ☐ Often ☐ Very often ☐ Explain:

• Does your spouse or partner have any specific health problem or emotional problem (include illness, handicap, alcohol or drug or gambling addiction, or mental illness)? Yes ☐ No ☐ N/A ☐ R/A ☐ Explain:

If "Yes", describe the impact that it has had on you:

92


如果合适,请探究以下问题: ・ 你们关系中的任何问题对于你有什么影响?

・ 如果你们的关系中有任何问题,离最早发生有多少时间了?

・ 你认为在这个关系中你被虐待了吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

有什么促成这个的因素吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

・ 在过去12个月里情况有没有更恶化? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

93


If applicable, explore the following questions: • What is the impact of any difficulties in your relationship?

• If there are any problems within the relationship, for how long has this been occurring?

• Do you describe yourself as being mistreated within this relationship? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

Is there any precipitating factor? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

• Have things become worse in the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

94


与子女的关系 12. 你有子女吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,跳转到第14题。 如果是,有多少子女? 探究对象和子女间的关系。如果有任何问题,是和谁? 请列出关系人: A: B: C: D:

描述任何发生的问题:

13. 是否有哪位子女有任何确切的健康问题或者情绪问题吗(包括疾病,残疾,酒精、毒品或赌博 成瘾,或者精神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

如果是,请描述这对你造成的影响:

这个人和你居住在一起吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

95


RELATIONSHIP WITH CHILDREN 12. Do you have any children? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" go to question 14 If "Yes" how many? Explore the relationship between the subject and the child(ren). If there are any problems, with whom? Please list relationship: A: B: C: D:

Describe any problems:

13. Does any child have any specific health problem or emotional problem (include illness, handicap, alcohol or drug or gambling addiction, or mental illness)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

If "Yes", describe the impact that it has had on you:

Does this person live with you? Yes ☐ No ☐ N/A ☐ R/A ☐

96


与孙子孙女的关系 14. 你有孙子孙女吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,跳转到第16题。 如果是,有多少孙子孙女? 探究对象和孙子孙女间的关系。如果有任何问题,是和谁? 请列出关系人: A: B: C: D:

描述任何发生的问题:

15. 是否有哪位孙子孙女有任何确切的健康问题或者情绪问题吗(包括疾病,残疾,酒 精、毒品或赌博成瘾,或者精神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

如果是,请描述这对你造成的影响:

这个人和你居住在一起吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

97


RELATIONSHIP WITH GRANDCHILDREN 14. Do you have any grandchildren? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" go to question 16 If "Yes" how many? Explore the relationship between the subject and the grandchild(ren). If there are any problems, with whom? Please list relationship: A: B: C: D:

Describe any problems:

15. Does any grandchild have any specific health problem or emotional problem (include illness, handicap, alcohol or drug or gambling addiction, or mental illness)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

If "Yes", describe the impact that it has had on you:

Does this person live with you? Yes ☐ No ☐ N/A ☐ R/A ☐

98


其他亲密关系 16. 你还有其他任何有亲密的人吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,跳转到第18题。 探究对象和其他亲密的人的关系。如果有任何问题,是和谁? 请列出关系人: A: B: C: D:

描述任何发生的问题:

17. 这些人中有人有任何确切的健康问题或者情绪问题吗(包括疾病,残疾,酒精、毒品或赌博成 瘾,或者精神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

如果是,请描述这对你造成的影响:

这个人和你居住在一起吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

99


OTHER SIGNIFICANT RELATIONSHIP(S) 16. Do you have any other significant relationships? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" go to question 18 Explore the relationship between the subject and the grandchild(ren). If there are any problems, with whom? Please list relationship: A: B: C: D:

Describe any problems:

17. Does this person have any specific health problem or emotional problem (include, illness, handicap, alcohol or drug or gambling addiction, or mental illness? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

If "Yes", describe the impact that it has had on you:

Does this person live with you? Yes ☐ No ☐ N/A ☐ R/A ☐

100


与其他家庭成员的关系 18. 你在过去12个月当中和任何其他家庭成员发生过问题吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,是什么问题?和谁发生的问题并且频繁程度如何?

19. 在其他家庭成员中是否有人有任何确切的健康问题或者情绪问题吗(包括疾病,残疾,酒精、 毒品或赌博成瘾,或者精神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

如果是,请描述这对你造成的影响:

这个人和你居住在一起吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

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RELATIONSHIP WITH OTHER FAMILY MEMBERS 18. Do you have any other family members with whom there have been problems within the past 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", what are they? With whom do they occur and how often?

19. Does any other family member have any specific health problem or emotional problem (include illness, handicap, alcohol or drug or gambling addiction,or mental illness)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

If "Yes", describe the impact that it has had on you:

Does this person live with you? Yes ☐ No ☐ N/A ☐ R/A ☐

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第3部分:关于日常生活能力的问题

依赖程度 20. 你是不是: 1. 在所有日常生活活动方面独立 ☐ 跳转到第25题 2. 在部分日常生活活动方面独立 ☐ 3. 完全依赖他人 ☐ 4. (如果适用)有多少人提供帮助? 请列出关系人: A: B: C: D:

在这个部分,使用上面和下面列出的分类来帮助你完成下面的表格。 对象面对不同的活动可能有不同的看护者帮助。 1. 无需帮助 2. 借助他人的帮助 3. 完全靠他人帮助 4. 不做该活动

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SECTION 3: QUESTIONS ABOUT ADL'S DEGREE OF DEPENDENCY 20. Are you: 1. Independent in all ADL's ☐ Go to question 25 2. Independent in some ADL's ☐ 3. Totally dependent ☐ 4. (If applicable) How many people provide assistance? Please list relationship: A: B: C: D:

In this section, use the categories listed above and below to help you complete the grid. Subjects may have different caregivers for different tasks. 1. Unaided 2. With assistance from others 3. Totally dependent on others 4. Activity not performed

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活动

帮助程度

指出每一项分别是暂时

谁协助该活动?

对象和看护者居

(1-4)

的还是永久的

(见上面的A-D)

住在一起吗?

洗澡 穿衣 上厕所 药物管理 家务 做饭 用餐 购物 交通 走动 其他

21. 直接询问对象关于他/她接受的照顾的类型以及与帮助他/她的人的关系的问题: ・ 你过去12个月里在受到的照顾方面有没有任何问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 请描述:

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Activity

Degree of Assistance (1-4)

For each item indicate if the situation is Temporary or Permanent

Who performs the activity? (see A-D, above)

Does the subject live with the caregiver?

Bathing Dressing Toileting Medication Administration Housekeeping Meal preparation Eating Shopping Transportation Mobility Other 21. Ask questions directly to the subject about the type of care that he/she receives and about the relationship with the person who helps him/her: • Have there ever been any problems with the type of care you received in the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ Describe:

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・ 你觉得这样的问题发生的频率如何? 1 只有一次 2 少数几次

3 每个月发生

4 每周发生

请说明:

・你有没有曾觉得你被剥夺了什么需要的东西?(例如:家用物品,食物,看医生的机会,假牙等等) 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请描述:

・ 这个人是否曾作出什么举动让你不高兴? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 你和那个人之间是否曾有过争论? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 这个人是否曾粗暴地对待过你? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・你是否得到了想要的食物? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ——质量上而言? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ——数量上而言? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

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• How frequently would you say that such a problem has occurred? 1 Only once 2 A few times 3 Monthly 4 Weekly Explain:

• Do you ever feel that you are being deprived of things that you need? (For example: household goods, food, going to doctors, dentures etc.) Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", describe:

• Has this person ever behaved in a way that upset you? Yes ☐ No ☐ N/A ☐ R/A ☐ • Have there ever been disagreements between you and that person? Yes ☐ No ☐ N/A ☐ R/A ☐ • Has this person ever handled you roughly? Yes ☐ No ☐ N/A ☐ R/A ☐ Do you have the food you want? Yes ☐ No ☐ N/A ☐ R/A ☐ – The quality?

Yes ☐ No ☐ N/A ☐ R/A ☐

– The quantity? Yes ☐ No ☐ N/A ☐ R/A ☐

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・ 有没有发生过一天甚至以上你都没有吃饱的情况? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 这个人是否曾拒绝带你去购物? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 是否曾有人让你觉得你没有价值或者是个负担? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

・ 你是否曾不情愿或者害怕要求你想要的东西? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

22. 你对以下的事情有没有过担忧: 1. 总会有人帮助的安全感 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 2. 受到的照顾的质量 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 3. 欠提供照顾的人的人情 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 4. 其他

是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

请说明:

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• Has there ever been a day or longer when you did not have sufficient food? Yes ☐ No ☐ N/A ☐ R/A ☐ • Does the person ever refuse to take you shopping? Yes ☐ No ☐ N/A ☐ R/A ☐ • Are you ever made to feel like you are worthless or a burden? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

• Are you ever reluctant or afraid to ask for things that you want or need? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

22. Do you have any concerns either in: 1. Feeling secure that help will always be available Yes ☐ No ☐ N/A ☐ R/A ☐ 2. Quality of the care that you receive Yes ☐ No ☐ N/A ☐ R/A ☐ 3. Feeling indebted to the person providing the care Yes ☐ No ☐ N/A ☐ R/A ☐ 4. Other

Yes ☐ No ☐ N/A ☐ R/A ☐

Explain:

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23. 在你最开始需要帮助之前,你与任何一位看护者之间的关系是否曾有问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

24. 是否有哪位看护者有任何确切的健康问题或者情绪问题吗(包括疾病,残疾,酒精、毒品或赌 博成瘾,或者精神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

如果是,请描述这对你造成的影响:

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23. Before you needed any help, were there ever problems in your relationship with any of your caregivers? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

24. Does any caregiver have any specific health problem or emotional problem (include illness, handicap, alcohol or drug or gambling addiction, or mental illness? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

If "Yes", describe the impact that it has had on you:

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第4部分:身体与精神健康状态 25. 你是否服用任何药物? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 26. 你是否知道每一种你正在服用的药物分别有什么用处? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 27. 在过去12个月中你的服药量是否增加了? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

28. 你是否饮用酒精类饮料? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 29. 在过去12个月中,你服用的酒精类饮料量是否增加了? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 30. 在过去12个月中,你是否感到更加忧愁或者沮丧? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

31. 在过去12个月中,你是否曾咨询过或者被转送给心理学家、社会工作者、精神病学家或者其 他类型的治疗师? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

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SECTION 4: PHYSICAL AND MENTAL HEALTH STATUS 25. Do you take any medication? Yes ☐ No ☐ N/A ☐ R/A ☐ 26. Do you know what each medication you are taking is for? Yes ☐ No ☐ N/A ☐ R/A ☐ 27. In the last 12 months has your consumption of medication increased? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

28. Do you consume alcohol? Yes ☐ No ☐ N/A ☐ R/A ☐ 29. In the last 12 months, has your consumption of alcohol increased? Yes ☐ No ☐ N/A ☐ R/A ☐ 30 In the last 12 months have you felt increasingly sad or depressed? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

31. In the past 12 months, have you consulted or been referred to a psychologist, social worker, psychiatrist or any other type of therapist? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", Explain:

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第5部分:与需要受照顾的人居住在一起 32. 你是否和任何一位需要依赖你照顾的人居住在一起? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,跳转到第34题。 如果是,你和这个人是什么关系?

你在以下类型方面是否给予受照顾的人帮助? ・ 洗澡 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 穿衣 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 上厕所 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 药物管理 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 家务 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 做饭 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 用餐 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 购物 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 交通 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 走动 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 其他(请描述): ・ 如果以上有任意一个为“是”,你和这个人之间发生过任何问题吗? 说明:

33. 这个人是否曾威胁或者冒犯你(无论是有意的还是无意的)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

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SECTION 5: LIVING WITH A CARE-RECEIVER 32. Do you live with anyone who is dependent on you? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" go to question 34 If "Yes" what it your relationship to that person?

Do you give any of the following types of assistance to the care-receiver? • Bathing Yes ☐ No ☐ N/A ☐ R/A ☐ • Dressing Yes ☐ No ☐ N/A ☐ R/A ☐ • Toileting Yes ☐ No ☐ N/A ☐ R/A ☐ • Medication administration Yes ☐ No ☐ N/A ☐ R/A ☐ • Housekeeping Yes ☐ No ☐ N/A ☐ R/A ☐ • Meal preparation Yes ☐ No ☐ N/A ☐ R/A ☐ • Eating Yes ☐ No ☐ N/A ☐ R/A ☐ • Shopping Yes ☐ No ☐ N/A ☐ R/A ☐ • Transportation Yes ☐ No ☐ N/A ☐ R/A ☐ • Mobility Yes ☐ No ☐ N/A ☐ R/A ☐ Other (Describe): • If "Yes" on any of the above, are there any problems between you and that person? Explain:

33. Does that person ever threaten or get aggressive with you (whether it is intention- al or not)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

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第6部分:家庭与社交活动 34. 你是否参加社交活动? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,请说明:

・ 你觉得你和子女、亲戚、朋友、邻居等人有足够的接触交流吗? 如果否,请说明:

・ 你参加家庭活动的频繁程度是否如你所愿? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 你参加社交活动的频繁程度是否如你所愿? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,请说明:

如果否,是什么原因阻碍了你? ・ 健康问题 ☐ ・ 没人带我一起 ☐ ・ 我想参加但是没有合适的机会 ☐ ・ 花费太高了 ☐ ・ 其他 ☐ 请说明:

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SECTION 6: FAMILY AND SOCIAL ACTIVITIES 34. Are you involved in social activities? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No", explain:

• Do you feel that you have enough contact with the children, relatives, friends, neighbors, etc..? If "No", explain:

• Are you involved in family activities as frequently as you would like to be? Yes ☐ No ☐ N/A ☐ R/A ☐ • Are you involved in social activities as frequently as you would like to be? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No", explain:

If not, what prevents you? • Health ☐ • No one to take me ☐ • Not enough availability of the activities that I would like to participate in 0 ☐ • Too expensive ☐ • Other ☐ Explain:

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・ 有没有你亲近的人曾阻止你参加社交活动? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

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• Has anyone close to you ever prevented you from participating in social activities? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

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第7A部分:对象的经济依赖性 35. 你感觉你现在经济状况如何? 1. 经济上可以自足 ☐ 2. 经济上部分自足 ☐ 3. 经济上完全依赖他人 ☐ 4. 不知道 ☐ 请说明:

36. 你的财务由谁来掌管: 1. 自己 ☐ 2. 借助他人的一些帮助 ☐ 3. 完全由他人掌管 ☐ 4. 不知道 ☐

37. 如果上面第36题的回答是2或3,那么你和这个人是什么关系? 1. 配偶/事实婚姻伴侣 ☐ 2. 子女 ☐

有多少人协助/管理财务?

3. 孙子孙女 ☐

有多少人协助/管理财务?

4. 侄子/侄女 ☐

有多少人协助/管理财务?

5. 朋友 ☐

有多少人协助/管理财务?

6. 其他:

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SECTION 7A: FINANCIAL DEPENDENCY OF THE SUBJECT 35. What is your perception of your financial situation? 1. Financially self-sufficient ☐ 2. Partly self-sufficient ☐ 3. Total financial dependence ☐ 4. Unknown ☐ Explain:

36. Are your finances managed by: 1. Self ☐ 2. With some assistance ☐ 3. Entirely by others ☐ 4. Unknown ☐

37. If "Yes" to number 36.2 or 36.3 above, what is your relationship to that person? 1. Spouse / common law partner ☐ 2. Child(ren) ☐

How many assisting/managing finances?

3. Grandchild(ren) ☐ How many assisting/managing finances? 4. Niece / nephew ☐ How many assisting/managing finances? 5. Friend ☐

How many assisting/managing finances?

6. Other:

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・ 谁来负责支付租金(抵押贷款或者财产税)?

・ 你和管理你财务的人之间是否曾经发生过问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

38. 你有没有委托任何人代理你行使银行业务? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,你和这个人之间曾发生过问题吗?

39. 你有没有完全授权给任何人?(经公证过)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,你和这个人之间曾发生过问题吗?

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• Who is responsible for paying the rent (mortgage or property taxes)?

• Have there ever been any problems between you and the person managing the finances? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

38. Does anyone have banking power of attorney? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", have there ever been any problems with this person?

39. Does anyone have total power of attorney? (notarized)? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", have there ever been any problems with this person?

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40. 你有没有签署过任何你感觉是被迫签署的文件? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,强迫你的人与你是什么关系?

这件事情的结果怎样?

41. 对那些由他人协助管理或者完全管理财务的对象询问以下问题(包括那些授权给他人的对象): ・ 你是否被告知所有的财产交易? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,这对你来说成问题吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 你是否曾担心或者怀疑你的钱没有按照你所想的那样被管理? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 在过去12个月里这是否成为了一个问题?是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 你的银行存款和你认为应当正确的数目一致吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,在过去12个月里发生过这样的问题吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 你的钱是否曾未经你同意而使用? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,在过去12个月里这是否成为了一个问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・ 你的所有账单是否定期支付? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,在过去12个月里这是否成为了一个问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

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40. Have you ever signed any documents that you felt you were forced to sign? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", what was your relationship to that person who forced you?

What was the outcome of this event?

41. Ask these questions to subjects who have assistance with managing their finances or have their finances managed by someone else (include those who have given power of attorney): • Are you informed about all financial transactions? Yes p No p N/A p R/A p If "No", is this a problem for you? Yes ☐ No ☐ N/A ☐ R/A ☐ • Have you ever had concerns or suspected that your money was not being managed as you would want? Yes ☐ No ☐ N/A ☐ R/A ☐ Has this been a problem within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ • Are your bank balances what you think that they should be? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No", is this a problem that has occurred within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ • Has your money ever been used without your consent? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", has this been a problem within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ • Are all your bills being paid regularly? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", has this been a problem within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐

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・ 如果以上问题中至少有一个对你构成了麻烦,你认为这类事情在过去12个月里发生的频率如 何? 1 只有一次 2 少数几次 3 每个月发生 4 每周发生 请说明前面提到的问题:

42. 总的来说,你是否曾感到有人觊觎你的钱? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

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• If any problem has been identified in any of the above questions, what would you say is the frequency of this type of situation within the last 12 months? 1 Only once

2 A few times

3 Monthly

4 Weekly

Explain problems mentioned:

42. In general, do you ever feel that anyone is after your money? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

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第7B部分:他人对对象的经济依赖性 43. 在过去12个月中,是否有任何人仰赖你的金钱资助? 是 ☐ 否 ☐ 有时 ☐ 不适用 ☐ 拒绝回答 ☐ 如果否,跳转到第49题。 如果是,是谁? ・ 配偶/事实婚姻伴侣 ☐ ・ 儿子 ☐ ・ 女儿 ☐ ・ 孙子孙女 ☐ ・ 侄女 ☐ ・ 侄子 ☐ ・ 其他:

上述选择的人当中是否有人也同时管理你的财务? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ ・如果是,是哪位?

44. 这个人和你一起居住吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

45. 这个人在经济上多大程度依赖于你? 1. 完全依赖 ☐ 2. 部分依靠 ☐ 3. 偶尔需要 ☐ 这是? 永久的 ☐ 暂时的 ☐ 请说明:(例如:目前失业,收入不够,残疾,其他)

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SECTION 7B: FINANCIAL DEPENDENCY OF SOMEONE ON THE SUBJECT 43. In the past 12 months, has anyone depend on you for money? Yes ☐ No ☐ Sometimes ☐ N/A ☐ R/A ☐ If "No", go to question 49. If "Yes", who? • Spouse / common law / partner ☐ • Son(s) ☐ • Daughter(s) ☐ • Grandchild(ren) ☐ • Niece(s) ☐ • Nephew(s) ☐ • Other:

• Does one of the above also manage your finances? Yes ☐ No ☐ N/A ☐ R/A ☐ • If "Yes", who?

44. Does that person live with you? Yes ☐ No ☐ N/A ☐ R/A ☐

45. To what degree is that person dependent on you financially? 1. Totally ☐ 2.  Partially ☐ 3.  Episodically ☐ Is this? Permanent ☐ Temporary ☐ Explain: (For example: presently unemployed, inadequate revenue, disability, other):

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46. 这个人有任何的身体或者精神健康问题吗(包括疾病,残疾,酒精、毒品或赌博成瘾,或者精 神疾病)? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

47. 这个人和你之间是否曾发生过有关财务的问题? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

48. 这个人是否曾虐待过你,无论是故意的还是无意的? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

・ 这种问题还在继续发生吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 请说明:

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46. Does this person have any physical or mental health problem (Include illness, handicap, alcohol, gambling or drug addiction, or mental illness? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

47. Has there ever been a problem regarding finances between you and that person? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

48. Has this person ever mistreated you whether it was intentional or not? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes", explain:

• Is that problem still going on? Yes ☐ No ☐ N/A ☐ R/A ☐ explain:

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第8部分:询问对象的总结性问题 访员陈述:(“我们的问题快要结束了,还只要检查一些问题”) 49. 是否曾有任何你亲近的人让你感到害怕或者威胁你? 1. 否 ☐ 2. 是,已经提到过了 ☐ 3. 是,还没提到过,请说明:

4. 如果上一题(49.3)回答是“是”,在过去12个月里这还继续发生吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果上一题(49.4)回答是“否”,那这是什么时候发生的事?

50. 你认为你认识的任何人是否通过任何方式虐待过你,无论是有意还是无意? 1. 否 ☐ (跳转到第51题) 2. 是,已经提到过了 ☐ 3. 是,还没提到过,请说明:

4. 如果上一题(50.3)回答是“是”,在过去12个月里这还继续发生吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果上一题(50.4)回答是“否”,那这是什么时候发生的事?

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SECTION 8: SUMMARY QUESTIONS TO ASK THE SUBJECT Interviewer states: ("We are coming near the end of our questions and we just want to go over a few more issue") 49. Has there ever been a time when you have felt scared or threatened by any one close to you? 1. No ☐ 2. Yes, already mentioned ☐ 3. Yes, not mentioned, explain:

4. If "Yes" to question 49.3, has this been going on within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" to question 49.4, then when did this occur?

50. Do you believe that any one you know mistreats you in any way, whether it was intentional or not? 1. No ☐ (go to question 51) 2. Yes, already mentioned ☐ 3. Yes, not mentioned, explain:

4. If yes to question 50.3, has this been going on within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" to question 50.4, then when did this occur?

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51. 你是否曾感到有任何亲近你的人在感情方面、身体方面(比如打你或者粗暴地对待你)、性方 面、财产方面伤害了你,或者忽视了你的某些日常需要,无论他们是意识到了还是没有意识到? 1. 否 ☐ (跳转到第52题) 2. 是,已经替代过了 ☐ 3. 是,还没提到过,请说明:

4. 如果上一题(51.3)回答是“是”,在过去12个月里这还继续发生吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果上一题(51 4)回答是“否”,那这是什么时候发生的事?

52. 总的来说,你对你亲近的人和你之间的关系满意吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐

53. 还有什么事情是你之前没提到但是想说的吗? 是 ☐ 否 ☐ 不适用 ☐ 拒绝回答 ☐ 如果是,请说明:

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51. Do you ever feel that anyone close to you is harming you emotionally, physically (such as hitting you or handling you roughly), sexually, financially or neglecting any of your daily needs - whether they are aware of it or not? 1. No ☐ (go to question 52) 2. Yes already mentioned ☐ 3. Yes, not mentioned, explain:

4. If "Yes" to question 51.3, has this been going on within the last 12 months? Yes ☐ No ☐ N/A ☐ R/A ☐ If "No" to question 51 4, then when did this occur?

52. In general, are you satisfied with your relationship with the people that are close to you? Yes ☐ No ☐ N/A ☐ R/A ☐

53. Is there anything that you would like to add that has not been mentioned before? Yes ☐ No ☐ N/A ☐ R/A ☐ If "Yes" describe:

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第9部分:给访员的问题 54. 你和对象所作的是单独访谈吗? 是 ☐ 否 ☐ 不适用 ☐ 如果否,还有谁在场,为什么?

55. 你认为对象在访谈期间是否诚实开放? 是 ☐ 否 ☐ 不适用 ☐ 如果否,请说明:

56. 对象是否能够全身心地参与访谈? 是 ☐ 否 ☐ 不适用 ☐ 如果否,请说明(例如:理解有困难,听力困难,不合作等等):

57. 在访谈过程中,你是否观察到对象表现出任何以下的情绪状态?在所有合适的选项上打勾: ・ 激进 ☐

焦虑 ☐

・ 羞愧 ☐

沮丧 ☐

・ 恐惧 ☐

无助 ☐

・ 生气 ☐

悲伤 ☐

・ 其他: 注释:

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SECTION 9: QUESTIONS FOR THE EVALUATOR 54. Were you able to interview the subject alone? Yes ☐ No ☐ N/A ☐ If "No", who was present and why?

55. Do you believe that the subject was being open and honest with you during the evaluation? Yes ☐ No ☐ N/A ☐ If "No", explain:

56. Was the subject able to fully participate in the interview? Yes ☐ No ☐ N/A ☐ If "No", explain (For example: difficulty understanding, hard of hearing, not cooperative etc):

57. During the interview, did you observe any of the following affective states in the subject? Check all that apply: • Aggression ☐

• Anxiety ☐

• Shame ☐

• Depression ☐

• Fear ☐

• Hopelessness ☐

• Anger ☐

• Sadness ☐

• Other: Comment:

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58. 你是否观察到任何虐待、忽视或者恶意对待的迹象?(例如:对象被照顾得很差,房屋乱糟 糟,没有食物,散发尿味,任何看得到的无法解释的伤痕或其他) 是 ☐ 否 ☐ 不适用 ☐ 如果是,请说明:

59. 你认为这位对象是否受到虐待? 1是☐ 2否☐ 3 不清楚 ☐ 请说明你的回答:

60. 如果上一题(59)回答为“是”,对象本人是否: ☐ 明确地说自己被虐待了? ☐ 用话语描述了该虐待? 请说明:

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58. Did you observe any signs of abuse, neglect or mistreatment? (For example: subject being poorly kept, house in disorder, no food, smell of urine, any visible and unexplained bruising or other) Yes ☐ No ☐ N/A ☐ If "Yes", explain:

59. Do you believe that this subject is being abused? 1 Yes ☐ 2 No ☐ 3 Don't know ☐ Explain your response:

60. If the answer to question 59 was "Yes", did the subject: ☐ State specifically that he/she was being abused? ☐ Used words to describe the abuse? Explain:

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61. 用形象的尺度来衡量,你对以下发现有多少自信?

心理虐待 不可能0

1确信

忽视 不可能0

1确信

身体虐待 不可能0

1确信

财产虐待 不可能0

1确信

62. 用形象的尺度来衡量,你对自己总的评估有多少自信? 毫无自信0

1非常自信

63. 你观察到的心理虐待、忽视(主动或被动)、身体虐待或者财产虐待的迹象和征兆有哪些? 如果适用,请说明: 心理虐待:

忽视:

身体虐待:

财产虐待:

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61. On a visual analogue scale, how confident are you in finding of:

Psychological abuse Unlikely 0

1 Likely

Neglect Unlikely 0

1 Likely

Physical abuse Unlikely 0

1 Likely

Financial abuse Unlikely 0

1 Likely

62. On a visual analogue scale, how confident are you in your overall assessment? Unconfident 0

1 Confident

63. What were the signs and symptoms that you observed of psychological abuse, neglect (active or passive) physical abuse or financial abuse? If applicable, explain: Psychological:

Neglect:

Physical:

Financial:

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64. 对象是否证实了他们受到: 不适用 ☐ 身体或性虐待 是 ☐ 否 ☐ 不知道 ☐ 请说明:

心理虐待 是 ☐ 否 ☐ 不知道 ☐ 请说明:

忽视 是 ☐ 否 ☐ 不知道 ☐ 请说明:

财产虐待或剥削 是 ☐ 否 ☐ 不知道 ☐ 请说明:

65. 对象是否面临直接的危险? 是 ☐ 否 ☐ 不知道 ☐

66. 对象是否需要或者想要被送交以接受某些帮助? 是 ☐ 否 ☐ 不知道 ☐

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64. Has the subject been able to confirm if they were: N/A ☐ Physically or sexually abused Yes ☐ No ☐ Unknown ☐ Explain:

Psychologically abused Yes ☐ No ☐ Unknown ☐ Explain:

Neglected Yes ☐ No ☐ Unknown ☐ Explain:

Financially abused or exploited Yes ☐ No ☐ Unknown ☐ Explain:

65. Is the subject in any immediate danger? Yes ☐ No ☐ Unknown ☐

66. Does the subject need or want to be referred for any help? Yes ☐ No ☐ Unknown ☐

144


67. 附加意见:

访员签名: 评估完成日期(年/月/日): 访谈时间长度(小时:分钟):

145


67. Additional comments:

Signature of Evaluator: Date written evaluation completed (yy/mm/dd): Duration of interview (hr: min):

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附录3:PAHO手册 第二部分: 虐待(恶意对待)和忽视(遗弃) 诊断和管理指导 I

泛美医疗组织 世界卫生组织地区办公室

目标: 1. 通过一种流行病学的视角来分析虐待与恶意对待问题,以采取反击行动。 2. 识别虐待与恶意对待的不同类型。 3. 描述相关联系的风险因素。 4. 描述对于受害者和施虐者的临床评估。 5. 描述最初的跟进策略。

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Annex 3: PAHO manual PART II: Abuse (Mistreatment) and Neglect (Abandonment) DIAGNOSTIC AND MANAGEMENT GUIDE I

PANAMERICAN HEALTH ORGANIZATION Regional Office of the WORLD HEALTH ORGANIZATION

OBJECTIVES 1. Analyze the problem of abuse and mistreatment by taking into account an epidemiological perspective, to take countering actions. 2.  Recognize the distinct types of abuse and mistreatment. 3.  Describe the associated risk factors. 4.  Describe the clinical assessment of the victim and the perpetrator. 5.  Describe the initial follow-up strategies.

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1– 问题的定义 老年人虐待被定义为任何类型的行为、一系列的行为或者某些行为的缺乏,导致对老人的身体 或者心理造成伤害,并且发生在信任或依赖关系之中。老年人虐待可能是家庭暴力循环的一部分; 它可能由看护者导致,也可能由缺乏培训的社会及医疗机构人员导致,当他们无法满足老人的需求 时。 老年人虐待和忽视会呈现出各种各样的形式: 身体虐待:造成伤害或者受伤,身体活动上的强迫,例如在没有正当理由的情况下阻止个人的 自由活动。同时也包括对个人的性虐待。 心理虐待:造成心理伤害,例如造成压力、焦虑,用侮辱的方式侵犯个人的尊严。 经济虐待:剥削一个人的财物,诈骗,勒索,以及偷取个人钱财。 忽视或遗弃:对依赖帮助或者应对其尽法律或道德义务的个人,忽视或者遗漏帮助的责任。忽 视或遗弃可能是故意的或者无意的。 故意的忽视指的是一位看护者由于自己的恶意或者不负责任,停止对老人提供需要的帮助。无 意的忽视指的是看护者在不知道或者缺乏能力的情况下没有提供帮助。

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1 – DEFINITION OF THE PROBLEM Elder abuse is defined as any type of action, series of actions, or lack of actions, which produce physical or psychological harm, and which is set within a relationship of trust or dependence. Elder abuse may be part of a cycle of family violence; it may be caused by caregivers, or may be the result of a lack of training of social and health institutions, who cannot meet the needs of older persons. Elder abuse and neglect may take diverse forms: PHYSICAL ABUSE: to cause harm or injury, to coerce physically, as for example to impede the free movement of an individual without justification. Also included in this category is the sexual abuse of an individual. PSYCHOLOGICAL ABUSE: to cause psychological harm, as for example causing stress, anxiety, and attacking the dignity of an individual with insults. ECONOMIC ABUSE: to exploit the goods of a person, fraud, blackmail, as well as theft of money or the property of an individual. NEGLECT OR ABANDONMENT: negligence or the omission of assisting or aiding an individual who depends on this help, or towards whom there exists a legal or moral obligation. Neglect or abandonment may be intentioned or unintentional. Intentioned neglect is when a caregiver, due to bad will or irresponsibility, ceases to provide an older person with the help this person may need. Unintentional neglect is when the caregiver does not provide assistance, either due to ignorance or incapacity.

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1.1 – 风险指标 老年人虐待可以由上面提到的4个类别代表,同时也会以不同的方式表现出来。(表格1.1)。 表格1.1 – 虐待的表现形式 身体虐待的种类 烫伤(用香烟、热水…)

用力推挤

弄伤

击打

导致骨折

强迫吃喝

拉扯头发

强迫处于难受的姿势

摇晃

捆绑

向其投掷或泼洒食物饮水

掐捏

性虐待 心理或情感虐待的种类

以抛弃相威胁

- 私人生活

没有正当理由的谴责

- 做决定

骚扰

- 获取医疗信息

身体动作或口头的恐吓

- 投票

将个人当做幼儿对待

- 收信

限制个人的以下权利:

- 与他人交流 财产虐待的种类

为了看护者自身利益利用老人的资源 财产勒索

占有个人财产 强迫签署法律文件,比如遗嘱、财产契约 等等 忽视或遗弃的种类

忽视个人的脱水状况 忽视个人的营养摄取 忽视未经治疗的溃疡 忽视个人的卫生情况

不清洗裸露的伤口 放任脏乱的环境 把人遗弃在床上、街上或社会公共机构里

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1.1 – Risk Indicators Elder abuse may be represented through the four categories mentioned, and may manifest itself in different ways (Table 1.1) Table 1.1 – Manifestations of abuse Types of physical abuse Types of physical abuse • • • •

Shoving Hitting Forcing someone to eat or drink something Forcing someone to be in an inappropriate position • To attach or bind someone • Pinching

• Burning (with cigarettes, fluids...) • Injuries or wounds Breaking bones Pulling Hair • Shaking • Putting or throwing food or water at someone • Sexual abuse

Types of psychological or emotional abuse • • • • • •

Threaten to abandon someone Non-justifiable accusations Harassment Physical or verbal intimidation Infantilizing the individual Limiting the rights of an individual to:

a private life take a decision medical information vote receive mail communicate with others

Types of financial abuse • Using the resources of the older person or the benefit of the caregiver • Financial blackmail

• To take possession of the property of an individual • Coercion to sign legal documents, such as wills, acts of property, etc

Types of neglect or abandonment • Neglecting the dehydration of an individual • Neglecting the good nutrition of an individual • Ignoring untreated ulcers

• • • •

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Neglecting the dehydration of an individual Not healing open wounds or lesions Maintaining an unhealthy environment Abandoning the person in bed, the streets, or a public institution


2 – 诊断的原则 2.1 – 风险因素 在家中:

・看护者的压力 ・老人的依赖程度 ・家庭暴力史 ・看护者的个人及经济困难 ・酒精或其他成瘾 ・对无行为能力的人需求的关注缺乏信息和资源 ・看护者的社会孤立 ・看护者缺乏支持和休息,当他/她要每周7天每天24小时地对一位残疾或者无行为能力的个人负 责。

在社会公共机构及社区养老院中:

・社会公共机构阻止或阻碍了老人与社会的交流。 ・该社会公共机构没有官方注册并缺乏认证。没有政府当局的控制与监督。 ・这些社会公共机构可能雇用那些缺乏正当的照顾脆弱及无行为能力者培训的服务人员、忽视或 者看护者。

・这些社会公共机构难以维持良好的工作人员及病人比例——这些病人可能严重的缺乏行为能力 或者患有痴呆——以便于满足这个脆弱群体的基本需求。

・在养老院中可能太过拥挤并且导致个人缺乏私人空间。 ・没有证据显示社区参与到了养老院的活动中。 ・社会公共机构的建筑构造可能不适合无行为能力以及行动不便的个人。

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2 – BASIS OF THE DIAGNOSTIC 2.1 – Risk Factors IN THE FAMILY: •

Caregiver stress

Level of dependence of the older person

History of violence in the family

Personal and financial difficulties of the caregiver

Alcoholism or other addictions

A lack of information and resources concerning the attention required to- wards a person with incapacities

Social isolation of the caregiver

Lack of support and rest for the care- giver, who is responsible for a disabled or incapacitated individual 24 hours per day, seven days per week

IN THE INSTITUTIONS AND COMMUNITY HOMES: •

The institution prevents or impedes contacts between the older individual and the community

This institution is not in an official registry and lacks appropriate accreditation. There is no control or surveillance by public authorities.

These institutions may hire attendants, nurses or caregivers who lack the proper training to care for people who are fragile and incapacitated.

It is difficult for the institutions to keep a good and necessary ratio between the staff and the patients, who may be severely incapacitated or suffering from dementia, in order to meet the basic needs of this vulnerable group.

There may be an overcrowding and a lack of private space for the individuals in the homes.

There is no evidence that the community participates in the activities of the home.

The physical structure of the institution is not adapted to the individuals who may be incapacitated and have problems with their mobility.

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2.2 – 问题的诊断 一位身体虚弱或者依赖他人的老人被虐待和忽视的迹象会呈现出许多不同的形式,因此要得出 虐待的嫌疑,建议医生应当对病人做一个彻底的评估,既通过身体检查也通过私人访谈。表格1.2提 出了指示有虐待最常见的指标。对问题的诊断的关键性步骤在图标1.1中呈现。

表格1.2 – 老年人虐待或忽视的可能性指标 类型

口述史

身体检查 存在伤口,尤其是存在多处并且具有不同的深度

身体虐待

对事实描述的改变,表现地不

以及愈合程度。脱水或者营养不良。存在未处理

可信或者和伤口不一致。

的伤口。有被束缚、捆绑或者击打的痕迹。有性 传播疾病。

药物虐待

因为用药错误频繁地医疗挂号 或者诊断。

有过度服药导致的中毒或者服药不足的迹象。

看护者和病人在被分别单独访谈的情况下,叙述 心理虐待

老人和家庭或者看护者之间存

和解释内容总体上有分歧。观察到部分看护者的

在富有矛盾的历史。

叙述不怎么尊敬老人或者将其看成幼儿。同时观 察到老人在看护者在场时总有难言之隐。

- 尽管有适当的指导和支持, 忽视

疾病还经常复发 - 存在未经治疗的健康问题。

卫生问题,营养不良,体温过低,未经处理的溃 疡,服药不足。

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2.2 – Diagnosis of the problem The symptoms of abuse and neglect of a frail or dependent older person may take on different forms, and it is recommended that should there be a suspicion of abuse or mistreatment, the doctor undertakes a thorough evaluation of the patient, both through a physical exam and a private interview. Table 1.2 presents the most common indicators of abuse or mistreatment. The critical paths of the diagnosis of the problem are presented in the Diagram 1.1. Table 1.2 – Indications on the Possibility of Elder Abuse or Neglect32 Type

History

Physical exam

Physical abuse

Changes in the description of facts, which are in any case improbable or in conflict with the wounds.

Presence of lesions, especially multiple and with differing levels of deepness and healing. Dehydration or malnutrition. Fractures of undetermined causes. Presence of wounds which were not taken care of. Signs that the individual may have been tied, bound, or hit. Sexually transmissible diseases.

By medication

Frequent medical admissions or consultations due to medication mistakes.

Signs of intoxication due to overmedication, or under-medication

Psychological abuse

In general the commentaries and explanations diverge when the caregiver and patient are interviewed separately. It has been observed History of conflict between the commentaries on the part of the caregiver older person and the family or which lowers the esteem or infantilizes the caregiver. older person. It also has been observed that the older person has difficulty speaking in the presence of the caregiver.

Neglect

– Recurring episodes of illness, despite proper education and support. – Untreated medical problems.

Hygiene problems, undernourishment, hypothermia, untreated ulcers, undermedication.

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图表1.1 – 老年人虐待或忽视的诊断指导方针

虐待或忽视?

可以怀疑,如果以下频繁出现: ・看护者和老人的叙述和解释内容之间有分歧 ・有无法解释的伤口 ・当老人不得不在看护者在场情况下回答问题时,表现出恐惧或者焦虑 ・严重的脱水或者营养不良

做一个详细的身体检查,

见表格1.1:“虐待的表现形式”。

包括实验室和X光。

私人访谈。见第4部分(干预)以及图

将怀疑内容写入文件,并且在下次访 问时保持警醒。

表1.3。 ・ 考虑法律上的含义。 ・ 通知专门保护老年人的服务部门 (如果国家里有)或者其他合适的权 威机构

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Diagram 1.1 – Diagnostic Guideline on Elder Abuse or Neglect34

ABUSE OR NEGLECT?

FREQUENTLY iT MAY BE SUSPECTED iN THE PRESENCE OF : • Commentaries and explanations diverge between the caregiver and the older person. • Presence of unexplainable lesions. • Fear or angst when the older person must answer to questions in presence of the caregiver. • Severe dehydration or undernourishment.

YES

NO

Undertake a detailed physical exam, including laboratory and x-rays.

See Table 1.1: “Manifestations of abuse”.

YES

NO

Write down suspicion in file, and stay alert during the next visit.

Private interview. See Section 4 (interventions) and Diagram 1.3. • Take into consideration the lega implications • Advise the services specializing in the protection of the elder (if they exist in the country) or other competent authorities.

158


3 – 诊断后治疗的原则 图表1.2 – 老年人虐待与忽视的治疗指导方针 筛查

有虐待或忽视的嫌疑。

没有虐待或忽视的嫌疑。

报告给成年人保护服务部门(在可行 的国家)。

有没有直接的危险?

对病人做一个完整的私人评估。

创建一个安全计划。

可选的内容:住院,法院保护令,安 置于安全的住所

评估: - 健康和行为状况

- 讨论安全问题。

- 安全性

- 安排完整评估的日程。

- 社会和经济资源 - 频繁程度与严重程度 - 认知状态 - 情绪状态

有理由相信虐待或忽视的发生。计划 进行干预。

未发现虐待或忽视。

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3 – BASIS FOR THE TREATMENT OF THE DIAGNOSIS Diagram 1.2 – Treatment Guideline on Elder Abuse and Neglect34 SCREENING

Abuse or neglect suspected.

Abuse or neglect suspected.

Report to Adult Protective Services (in the countries where available).

Is there an immediate danger?

YES

Undertake a full, private assessment with the patient.

NO

YES

Create a safety plan. Options include: hospital admission, court protective order, and safe home placement.

ASSESSMENT: - Health and performance status -  Safety -  Social and financial resources -  Frequency and severity -  Cognitive status -  Emotional status

Reasons to believe the abuse or neglect occurred. Plan intervention.

NO

- Discuss safety issues. -  Schedule for full assessment.

No abuse or neglect found.

160


3.1 – 干预计划 在每个虐待或忽视的案件中,是否干预主要取决于老人个人是否同意被提供帮助,以及老人的 决定能力。干预的水平取决于该国家可以提供的保护老人的服务水平。我们在图表1.3中建议了一个 发展一般性项目的方法,并请你决定在你所处的地区采用何种途径。 图表1.3 – 虐待或忽视的干预方案 干预

协调与成年人保护服务部门的或者你的国家所指定的机构的合作途径

病人愿意接受志愿服务

病人不愿意接受志愿服务或者缺乏做出同意的能力

・ 教育病人关于老年人虐待与忽 视的发生,以及随着时间推移

病人没有能力做决定

病人有能力做决定

与合适的权威部分讨论以下

・ 教育病人关于老年人虐

发生频率逐渐增加的趋势。 ・ 实施一个安全计划(例如:安 全住所,法院保护令,住 院)。 ・ 提供缓解虐待起因的帮助(例

的可选方案或者服务:

随着时间推移发生频率 ・ 财务管理援助 ・ 提供保护者

如:将看护者送交到毒品或酒 精戒除康复中心,为看护者及 老人提供教育、家庭健康以

待与忽视的发生,以及

・ 特殊的法律程序(例如: 保护令)。

及/或者家政服务)。

逐渐增加的趋势。 ・ 提供关于应急电话号码 及合适的转送机构的书 面信息。 ・ 准备并审阅安全计划。

・ 为病人以及/或者家庭成员推

・ 准备一个跟进计划。

荐合适的服务(例如:社会工 作,咨询服务,法律援助)。

161


3.1 – Intervention Plan In every case of abuse or neglect, the intervention will depend principally on the acceptance by the older individual of the offer of assistance, as well as the person’s capacity to decide. The level of intervention will depend on the services for the protection of the elderly available within the country. We suggest a way to develop a general program in Diagram 1.3, and ask you to decide what path to take in your region. Diagram 1.3 –Intervention scheme in case of abuse or neglect INTERVENTIONS

COORDINATE APPROACH WITH ADULT PROTECTIVE SERVICES OR AS MANDATED IN YOUR COUNTRY

PATIENT IS WILLING TO ACCEPT VOLUNTARY SERVICES

• Educate the patient about the incidence of elder abuse and neglect, and the tendency for them to increase in frequency and severity over time. • implement a safety plan (ex: safe home, court protective order, hospital admission). • Provide assistance that will alleviate causes of mistreatment (ex: refer the caregiver to a drug or alcohol rehabilitation clinic, provide education, home health, and/or homemaker services for both caregiver and older person).

PATIENT IS UNWILLING TO ACCEPT VOLUNTARY SERVICES OR LACKS CAPACITY TO CONSENT

PATIENT WITHOUT THE CAPACITY TO DECIDE Discuss with appropriate authorities the following services or options: • Financial management assistance. • Conservatorship or Guardianship. • Special court proceedings (ex: orders of protection).

PATIENT WITH THE CAPACITY TO DECIDE • Educate the patient about the incidence of elder abuse and neglect, and the tendency for them to increase in frequency and severity over time. • Provide written information on emergency numbers and appropriate referrals. • Develop and review safety plan.

• Referral of patient and/or family members to appropriate service (ex: social work, counselling services, legal assistance).

• Develop a follow-up plan. 162


4 – 需要记住的关键点

・ 虐待与忽视是医疗护理人员中很少有人了解的问题。 ・ 它们在每天的老年人问诊当中出现。 ・ 它们发生在老年人身上。 ・ 心理及财产虐待、以及忽视和遗弃是对老年人来说最常见的虐待与恶意对待的形式。 5 – 推荐阅读文献

American Medical Association: Diagnostic and Treatment Guidelines on Elder Abuse and Neglect, 1992, Chicago: AMA. International Network for the Prevention of Elder Abuse. www.inpea.net Lachs MS, Pillemer K: Abuse and Neglect of Elderly Persons. NEJM 1995; 332:437-442. National Center on Elder Abuse. www.elderabusecenter.org World Health Organizations: Missing Voices. Views of Older Persons on Elder Abuse, 2002, WHO/ NMH/VIP/02.1. www.who.int/hpr/ageing/elderabuse.htm Yoshikawa TT, Cobbs EL, Brummel-Smith K: Elder Mistreatment. Abuse and Neglect. In: Practical Ambulatory Geriatrics, p.134, 1998 (2nd Ed.).

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4 – KEY POINTS TO REMEMBER •

Abuse and neglect are problems which are little known within the health profession.

They appear daily during geriatric consultations.

They happen to older people.

Psychological and financial abuse, with neglect and abandonment are the most common forms of abuse and mistreatment towards older people.

5 – SUGGESTED READINGS American Medical Association: Diagnostic and Treatment Guidelines on Elder Abuse and Neglect, 1992, Chicago: AMA. International Network for the Prevention of Elder Abuse. www.inpea.net Lachs MS, Pillemer K: Abuse and Neglect of Elderly Persons. NEJM 1995; 332:437-442. National Center on Elder Abuse. www.elderabusecenter.org World Health Organizations: Missing Voices. Views of Older Persons on Elder Abuse, 2002, WHO/ NMH/VIP/02.1. www.who.int/hpr/ageing/elderabuse.htm Yoshikawa TT, Cobbs EL, Brummel-Smith K: Elder Mistreatment. Abuse and Neglect. In: Practical Ambulatory Geriatrics, p.134, 1998 (2nd Ed.).

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上海新途社区健康促进社 地址:浦东新区峨山路613号A楼201室 电话:021-58751368 网址:www.xintu.org

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老年人虐待与忽视的全球应对  

老年人虐待与忽视的全球应对

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