Elder mistreatment is now recognized internationally as a serious public health problem. However, current scientific knowledge regarding this problem in China is still lacking. To our knowledge, this is the first population-based study examining the prevalence of elder mistreatment in a rural community in China. In this study, we found that elder mistreatment was common, with an estimated prevalence of 36.2% in the previous 12 months. The present estimate of overall elder mistreatment was much higher than estimates obtained from studies done in Western countries 
. In addition to the overall prevalence, results from this study confirm the findings of other studies that indicate psychological mistreatment and neglect are the most common types of elder mistreatment 
Elder mistreatment, like any other form of family violence, is extremely complex, and various factors contribute to its occurrence. In our study, we found that several factors were associated with elder mistreatment. Depression, being widowed/ divorced/ single/ separated, having physical disability, having a labor-intensive job, depending on self-made income, and living alone significantly increased the risk of elder mistreatment. Our findings are similar to a study done by Dong et al 
, in which depression, as defined by positive responses on five questions of the Geriatric Depression Scale, was significantly associated with elder mistreatment. In contrast to previous research, our study showed that elder people living alone were more likely to fall victim to mistreatment. Most studies have indicated that a shared living situation is a major risk factor for elder abuse and that people living alone are at lowest risk 
. There are increased opportunities for contact and thus perhaps conflict and tension in a co-residential living arrangement. It is a Chinese cultural norm and value for adult children to take responsibility for providing care for their older parents, and elderly people prefer to live with adult children (particularly the eldest son and his wife and children) for emotional, physical, and financial support 
. Living alone can make older people feel isolated and neglected by their families and relatives. Studies have shown that living alone is associated with lower subjective well-being among the Chinese older people 
. On the other hand, living alone may be the result of elder mistreatment rather than a risk factor. Selfish adult children might be tired of taking care of their older parents and therefore force them to live alone. This phenomenon was frequently observed in our field survey.
Depending on self-made income was related to a higher level of mistreatment. A possible explanation for this result is that the abuser might have financial difficulties and extort the elder adult's property, resulting in mistreatment 
. It has been reported that having adult children depending on elderly parents for housing and financial assistance increases the risk of elder mistreatment 
. Unlike developed countries where social security systems are well established, China does not have a good welfare or social security system for its elders. Especially in rural areas where the majority of Chinese older people reside, family is usually the main or only source of financial support. Similar to living alone, financial independence might be the result of elder mistreatment. If adult children neglect elder parents' basic needs, those elders have to depend on self-made income, which may be viewed by the elder as a mistreatment. Our study also showed that high labor intensity was associated with higher risk of elder mistreatment. A labor intensive job held by elder adults may be associated with a dependence on self-made income or insufficient financial support from children.
It was reported that older women were at higher risk of elder mistreatment compared with their male counterparts 
. Rural older women in China have lower socio-economic status in family and tend to dependence on financial and emotional support from their children 
, thereby might impose a higher risk of mistreatment on them. But we did not find the gender difference of elder mistreatment in this study. We speculated the possible reason for this finding was that older women rather than older man in China were responsible for domestic chores, such as cooking, cleaning, taking care of grandchildren, which might win the respect from their children, and in turn, reduce the mistreatment risk.
In this study, we found that risk factors varied somewhat by mistreatment type, but the three most common types of elder mistreatment were associated with depression, even after we controlled for the effects of all other variables that were tested. This finding was consistent with previous studies 
. Older adults who reported depression had increased risk of suffering mistreatment.
Our study demonstrated that physical disability and chronic diseases were independent variables for psychological mistreatment. Caring for elder parents with physical disabilities and chronic diseases requires substantial support and often personal sacrifice on the part of the caregivers and other family members 
. This can put undue stress on the caregiver's physical, psychological, and economic status. It is possible that caregivers with excessive stress often fail to provide the necessary daily care to their elder parents. In addition, there is a high likelihood that the stressed caregiver could be responsible for mistreatment.
There are several limitations that must be taken into consideration in our study. First, although the study region was a typical rural area of Hubei province and had levels of economic development and modernization comparable to those in other provinces of rural China, caution should be exercised in generalizing our findings to China's 100 million rural older residents. Furthermore, our results should not be extrapolated to populations in urban areas of China with a different social culture and lifestyle. Second, this was a cross-sectional study, and its results represented associations between variables only. It is not appropriate to make inferences regarding cause and effect among these variables. Future prospective studies are needed to explore the causal and temporal associations between the variables identified in this study. Third, information regarding elder mistreatment was obtained by participant self-report. The validity of elderly adults' answers might be distorted by recall bias. Fourth, characteristics of perpetrators such as mental illness, alcohol and other substance abuse were reported to increase the risk of elder mistreatment 
, but our study considered only characteristics of the victims of mistreatment and not the abusers. Finally, the estimated prevalence rate for self-reported elder mistreatment in study sample might underestimate the actual situation as cognitively impaired adults (at greater risk of elder mistreatment) were excluded. Traditional Chinese culture has a deep-rooted idea that every family has difficulties and that outsiders should not meddle with another's family affairs. These types of issues are “family matters” that should be handled within the family. Furthermore, because the abusers are often members of the family, there is a tendency for family members to cover up the situation. In addition, there is a tendency for the victim to protect the abuser from “getting in trouble.” Consequently, it is possible that our study underestimated the occurrence of elder mistreatment in this rural Chinese community. Nevertheless, this study does provide some preliminary results about elder mistreatment and its risk factors in a Chinese rural population. In spite of these limitations, it is noteworthy that various forms of elder abuse as identified by Western countries are also present in Chinese rural areas. Some of the risk factors for elder mistreatment in this Chinese rural community are consistent with those found in Western countries.
Elder mistreatment is relatively unexplored in Chinese society. Results obtained in this study suggest that the prevalence of elder mistreatment is high in rural communities of China. This study has potential implications not only for health care professionals, but also for community policies concerning assessment, treatment, and prevention strategies. Health care professionals should pay special attention to elder adults with physical disabilities, those who are widowed, divorced, single or separated, and those with depression because they may be at an increased risk of mistreatment. Furthermore, social services agencies should be aware of risk factors for elder mistreatment and devise detection, intervention, and prevention strategies to address such mistreatment in an effort to improve the health and wellbeing of older adults.