Nannies go rogue? A call for research into nanny-induced elder abuse in China

Summary

How well society treats its elderly often speaks volumes. From cultural roots, social norms, established traditions, to newly formed habits, the respect and dignity older people receive, or lack thereof, often reveal the depth and breadth of a country’s care and respect for basic human rights, like people’s rights to health. As revealed by coronavirus disease 2019 (COVID-19), especially the discriminatory social media postings that are often adorned with hashtags such as ‘Coffin Dodger’ or ‘Boomer Remover’,¹ elderly abuse can spread exponentially in a short span if effective interventions are not in place. Elder abuse is defined as ‘a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’.² Despite China’s ingrained cultural traditions and practices of Confucianism—a philosophy that respects the elderly greatly, when it comes to social malaise like elder abuse, China is no stranger. Globally, it is estimated that approximately one in six people aged 60 years and over face abuse.³ Prevalence in China is similar: in a 2020 study of 10 362 older people in Hunan Province, for instance, researchers found that around 1596 (15.4%) participants had been physically, emotionally, or financially abused; among which, 31.2% had faced two or more types of abuse.⁴

While already alarming, these numbers are likely underrepresenting the severity of the situation for three reasons. Firstly, in China and elsewhere, rather than a celebratory experience, elder abuse is often associated with shame and stigma. This, in turn, could result in underreporting of abuse in surveys that are reliant on subjective input. Secondly, compared to their younger counterparts, older people in China, especially those living in rural or otherwise less developed regions, are more likely to be illiterate and stay so, which could further prevent them from participating in survey studies. Thirdly, and arguably with greater repercussions, many older people might face severe cognitive or physical impairment that would prevent them from participating in surveys that often require participants to be able to communicate effectively. According to the 2020 Report on Chinese Residents’ Chronic Diseases and Nutrition, for instance, almost all chronic conditions—from diabetes, hypertension, to hypercholesterolemia—were on a 2.2–8.7% rise in the country compared to 2015 data.⁵ It is estimated that, even accounting for overlaps between patients, the population that has chronic conditions may have reached between 0.5 and 0.6 billion people or 35–45% out of China’s total 1.4 billion population.⁵ Also considering factors such as (i) the country’s lack of effective interventions to slow or reverse its rising chronic disease crisis, (ii) diseases like diabetes are increasingly found in younger populations, (iii) the repercussions of COVID-19 such as long COVID on China’s population health and healthcare capacity and (iv) China’s fast-paced population ageing, it is likely that more people in China will face debilitating conditions that would require themselves, their families or friends to seek outside caregiving help.

Yet China’s caregiving industry is burdened with challenges as well. Unlike their Western counterparts, while China’s elderly are less likely to be exposed to toxic social media remarks thanks to China’s stringent online content censoring mechanisms, the situation is drastically different for offline abuse and neglect. Different from the country’s excellent performance at content screening, the government is less competent in eradicating or curbing in-person abuse, which often takes varied and more severe forms of harm, ranging from physical abuse, psychological abuse, material exploration, sexual abuse, to neglect. One particularly obstinate source of elder abuse in China, for instance, comes from care workers. In a 2020 observational study conducted on 156 professional caregivers in three long-term care facilities in Guangzhou, China, for instance, the findings show that 51.9% of the caregivers displayed some tendency of abuse towards elderly people living with dementia.⁶ This finding is largely in line with the global trend, especially factoring in common limits of observational studies like the behavioural bias of the observed participants. In a systematic review study that covered 14 academic databases, for instance, the researchers found that 64.2% of staff in institutional care facilities like nursing homes had committed elder abuse as recently as the past year.⁷

However, a review of the literature shows that there is a dearth of research on elder abuse in residential settings. This is important, as in China, due to its cultural roots and social norms, older people’s care experiences often follow the ‘721’ rule: 70% of older people receive care at home, 20% from the community and 10% from institutional care facilities. What is more concerning, however, is research that focuses on the type of care workers that many—if not the majority—of Chinese families hire for elderly caregiving—namely, nannies. Different from Western countries, nanny (‘bao mu’) is used as an umbrella term for people who offer caregiving help in residential settings at large, regardless of the age of the care recipients. In China, there are often three types of care workers people could seek for elderly care: state-certified nurses (or ‘hu shi’), non-state-certified formal caregivers (e.g. ‘hu gong’) and nannies (for a detailed comparison, please see Table 1). The lack of research on elder abuse from nannies is particularly worrisome as, different from nurses or caregivers, professions which often require systematic, if not rigorous, education, training and evaluation processes, nannies, by law, are not required to be screened through any, let alone rigorous, training, evaluation, of certification processes.

In practice and reality, almost anyone can become a nanny in China. Even though a background check is often required, this process is highly variable and dependent on the specific labour agencies that nannies are registered with. The compounding impacts of Chinese nannies’ lack of training, evaluation and even background screening mean that not only that nannies may not have the knowledge and skills needed for caregiving, they may also lack the critical ethical understanding and moral grounding of the caregiving practice. This, in turn, may explain why nanny-induced elder abuse seems to be a perennial problem in China. In 2023 alone, for instance, a wide range of media coverage of nanny-induced elder abuse has shocked the country, which spans from verbal, physical, psychological, financial, to sexual abuse. In one incident, a nanny was found, with the help of surveillance cameras, abusing her care recipient—a 69-year-old disabled and bed-bound woman—verbally, physically and sexually, even though the older woman’s son had just given the nanny a pay raise recently.⁸ Also in 2023, a nanny was recorded asking her 87-year-old care recipient to eat the excrement that the old lady uncontrollably left on the bed sheet yet was too embarrassed to admit when asked.⁹ Similar incidents have happened before in China. In 2020, a nanny was arrested for abusing a 77-year-old man with both cognitive and physical disabilities.¹⁰ Partly captured by surveillance cameras, the nanny not only constantly beat the old man and broke his hand, but she was also recorded frequently trying to force used adult diapers into the elderly’s mouth.

While these incidents are both shocking and disheartening, they might only represent a small portion of elder abuse by nannies in China. One way to truly understand the scale and severity of the issue is via rigorous research into the phenomenon. For starters, systematic efforts, such as long-term research funding and government-led investigation into the issue, have the potential to yield more evidence-based insights and solutions into curbing elder abuse caused by nannies and other care workers. More nuanced academic research could also help paint a fuller picture of nanny-induced elder abuse in China, from macro-factors (e.g. government oversight and policy-making), meso-factors (e.g. labour agency’s screening and evaluation processes), to micro-factors (e.g. nannies’ professional and psychological evaluations). For instance, structured research could help answer one of the most important global priorities identified by the World Health Organization in combating elder abuse: How to ‘develop and scale up cost-effective solutions to stop abuse of older people’.² Considering China’s unique cultural and societal characteristics, which are often markedly different from those of the developed or Western countries, it is then of critical importance that researchers investigate strategies that are more suitable for the Chinese context, as opposed to borrowing existing solutions from other societies. For instance, though Chinese older people’s preference towards ageing at home—where they could be in a familiar environment and close to families and friends—might be difficult to change, digital health solutions—from smart sensors and monitors, virtual hospitals that would enable hospital-at-home care solutions, to generative artificial intelligence like ChatGPT-powered care chatbots—have the potential to create guardrails against abuse from nannies and beyond. Overall, more research is needed to understand and curb elder abuse in China. It is our hope that this article could inspire studies to help society create a safer and more sustainable ageing environment for the ageing population in the long run.

Authors’ contributions

Z.S., D.M.D., B.L.B., W.D., Y.D., Y.F., S.K., P.M., T.A., D., X.W., J.J., Y.L., X.Y., X.Z., J.B.N., C.P.d.V. and Y.T.X. conceived the work, reviewed the literature, drafted and edited the article. All authors approved the article for submission.

Funding

Funding support for this article was provided by the “The Fundamental Research Funds for the Central Universities” (4025002306).

Conflict of interest

None declared.

Data availability

Data are available upon reasonable request.

Acknowledgements

The authors wish to express their gratitude the editors and reviewers for their constructive input and insightful feedback.

References