INTERNATIONAL HEALTH AFFAIRS
Who Wants to Enter a Long-Term Care Facility in a Rapidly Aging
Non-Western Society? Attitudes of Older Koreans Toward
Long-Term Care Facilities
Eun-Young Kim, PhD, and Chang-yup Kim, MD, PhD
To estimate future demand for institutional long-term care
(LTC) by Koreans, the intention to use LTC facilities was
estimated, and the underlying influencing factors were ex-
plored. Data from the Korean National Survey of LTC
Need in the Elderly compiled in 2001 were used, and 1,850
people aged 65 and older who were classified as the targets
for LTC in the survey and for whom complete data were
available were sampled. The following influencing variables
were selected based on Andersons service-use model:
demographics, social structural factors, family and com-
munity resources, and felt and assessed needs. The result
shows that, of all the participants, 18.8% intended to use
LTC facilities. A stronger intention was related to younger
age, Christian religion, fewer children, lower family in-
come, higher chronic comorbidity, and more education.
The rapid industrialization of Korea has lead to a transition
from the traditional family-centered mode of caregiving to a
nontraditional one, but the intention to use LTC facilities is
still lower than in Western developed countries. Regarding
family resources, the effect of extended families comprising
three or more generations is not as significant as expected,
but children continue to be regarded as the main resources
for LTC. The recent introduction of nontraditional religions
to Korea has had a positive effect on intention to use LTC
facilities, suggesting that cultural factors influence their use.
J Am Geriatr Soc 52:21142119, 2004.
Key words: long-term care; residential facilities; utiliza-
tion; Korea
T he population of Korea is aging rapidly. The time to
make the transition from an aging society (defined as
7% of the population being elderly) to an aged society
(14% elderly) was 115 years for France, 72 years for the
From the Seoul National University School of Public Health, Seoul, Korea.
Funded by Korea Research Foundation Grant KRF-2002050-E0003.
Address correspondence to Chang-yup Kim, MD, PhD, MPH, Seoul National
University School of Public Health, 28 Yongon-dong, Chongno-gu, Seoul
110799, South Korea. E-mail: cykim@snu.ac.kr
JAGS 52:21142119, 2004
r 2004 by the American Geriatrics Society
United States, 47 years for the United Kingdom, and 24
years for Japan, but this change is expected to take only 19
years in South Korea (hereafter Korea).1 As a result, the
need for long-term care (LTC) is also increasing rapidly. It
has been estimated that 20.9% of people aged 65 and older
need LTC services because of their need for assistance with
activities of daily living (ADLs); 18.9% need in-home serv-
ice, and 2% need institutionalized care.2
The current supply of LTC facilities in Korea is insuf-
ficient. There are diverse types of facilities that fall into
three major categories: (1) board and care, (2) nursing
home, and (3) LTC hospital. The former two provide serv-
ices for elderly people with low-level medical needs and are
usually differentiated according to the severity of functional
impairment of the people they serve. The welfare section of
the Ministry of Health and Welfare (MOHW) manages
these types of facilities and subsidizes the service for the
poor. In contrast, LTC hospitals belong to the medical sec-
tion of the MOHW and depend on national health insur-
ance for financing. As of December 2002, 120 board and
care facilities, 51 nursing homes, and 54 LTC hospitals were
caring for about 18,000 people in Korea, which represents
less than 1% of the elderly population.3,4 Except for poor
people (defined according to specific governmental criteria)
whom the government subsidizes, users of board and care
facilities and nursing homes pay for all the services them-
selves. Although reimbursed by national health insurance,
LTC hospitals are associated with a high rate of copayment,
with users paying about 50% of the expenses themselves.5
The insufficient supply of facilities and the financial impli-
cations for some of using LTC services make them unat-
tractive to many Koreans. In addition, cultural factors
contribute to the reluctance of elderly people to enter into
an LTC facility and be cared for by people other than im-
mediate family members.
[Editors note: The organization and extent of services
for the elderly have recently been described in this journal
(Cho K-H, Chung Y, Roh Y-K et al. Health Care for Older
Persons: A Country ProfileFKorea. J Am Geriatr Soc
2004;52:11991204).]
Nevertheless, the need and demand for LTC services
are rapidly increasing, and the future supply of LTC
0002-8614/04/$15.00
JAGS DECEMBER 2004VOL. 52, NO. 12
facilities should be planned based on objective measures of
need and demand. In this regard, it is of interest to deter-
mine how many of the people in need will use LTC facilities.
Various factors influencing the need for LTC translate into
demand and utilization. One is the intention to use LTC
facilities, in which intention is defined as the persons sub-
jective probability that he/she will perform the behavior in
question.6 A previous study revealed that the intention to
use LTC facilities was associated with a 1.5-fold increased
probability in their eventual uptake.7 Furthermore, another
study discovered that the intention to use was the most
important predictor of future use of LTC facilities.8
Diverse factors influence the intention to use LTC fa-
cilities, with the need for LTC due to chronic diseases or
functional decline being one of the main ones. Demographic
and socioeconomic factors, including age, sex, marital sta-
tus, and education level, also significantly influence inten-
tion.9 In particular, having no spouse or children, living
alone, low family income, and insufficient family resources
are strongly related to the intentionFand hence future
probabilityFof using LTC facilities.10 Additionally, culture
has a strong influence on the intention to use LTC facilities.
For example, in the United States, the attitude toward
the use of LTC facilities in traditionally family-centered
groupsFwhich tend to be nonwhiteFis more negative
than in whites.4 Moreover, it was found that Japanese
Americans who had become acculturated into American
society, and had never lived in Japan and could not speak
Japanese, had high intentions to use LTC facilities.11
Korea is a newly industrialized country and faces
strong challenges to its traditional ways of life. Of these
challenges, rapid changes in the family structureFfrom
extended families comprising three or more generations to a
nuclear family with only parents and childrenFhave led to
a decrease in the availability of care provided by family
members. Nevertheless, social and individual expectations
of the provision of self-care by family members remain
high, because of traditional attitudes toward LTC and be-
cause of the poor accessibility to LTC services provided by
nonfamily members. This suggests wide gaps between the
need, intention, and actual use of LTC facilities.
From this perspective, this study aimed to explore the
factors influencing the intention of Korean elderly to use
LTC facilities. The hypothesis was that the intention of
Korean elderly to use LTC facilities would be rather weak
but that those with a less-traditional perception of LTC
would have a more positive attitude toward their use.
METHODS
Conceptual Model
For the analysis, Andersons behavioral model of health-
service use was slightly modified.12 The determinants of
service use were adopted, but elements of each factor were
adjusted according to the following characteristics of LTC:
predisposing factors (age, sex, marital status, education
level, and religion), enabling factors (number of children,
family structure (nuclear family and extended family), fam-
ily income, and place of residence), and need factors (self-
rated health, ADLs, instrumental ADLs (IADLs), cognitive
level, and comorbidity). The intention to use a service
OLDER KOREANS ATTITUDES TOWARD LTC FACILITIES 2115
replaced the service utilization in the original model as an
intervening factor before service use.79,13
Methodology
The data source for this study was the 2001 National Sur-
vey of LTC Need in the Elderly, conducted by the Korea
Institute for Health and Social Affairs.2 This was a nation-
wide interview survey of the noninstitutionalized popula-
tion. It sampled 5,351 people aged 65 and older using a
random stratified cluster method and completed interviews
with 5,058 people. Of these, the survey defined 2,293 peo-
ple (45.3%) as targets for LTC, based on the criteria of
more than one limitation in ADLs or IADLs or scores lower
than 20 on the Mini-Mental State Examination (MMSE)
(definite dementia). The results of previous studies and ex-
pert consensus in Korea set these criteria.2 The current
study population consisted of these 2,293 people. Finally,
excluding respondents for whom complete information was
not available, data from 1,850 (80.7%) people were analy-
zed. There was no significant difference of age and sex dis-
tribution between the study population and the analyzed
population.
From the original survey data, information was ex-
tracted on the following variables selected according to the
conceptual model: age, sex, marital status, educational at-
tainment, religion, number of children, living arrangement,
family structure, family income, place of residence, self-
rated health, ADLs, IADLs, MMSE score, and chronic co-
morbidity.
In the survey, physical function was measured using
ADLs and IADLs. The measurement tools were the Korean
versions of the ADL and IADL indexes developed and val-
idated by the Korean Geriatrics Society and similar to ver-
sions in other languages.14 This ADL index comprises seven
items: dressing, washing the face, bathing, eating, transfer,
toilet use, and continence. The IADL index comprises 10
items: grooming, performing housework, preparing meals,
doing laundry, going out to nearby places, transportation,
shopping, managing finances, telephone use, and managing
medication. Each item is assigned one of three scores:
absolute independence, partial dependence, or absolute
dependence. The MMSE was used to measure cognitive
function.15 It examines orientation, registration, attention/
calculation, language, and recall. The lowest score is 0
and the highest 30; a score of 20 to 23 is regarded as sus-
pected dementia, and less than 20 is classified as definite
dementia.2
Analyses
First, descriptive statistics were measured to understand the
basic characteristics of respondents. Additionally, to anal-
yze the factors affecting intention to use LTC facilities, lo-
gistic regression was performed with intention to use as the
dependent variable. Predisposing factors, enabling factors,
and need factors were input as independent variables in the
model. Of the variables, age was categorized into younger
old (o75) and older old (  75). Other variables were cat-
egorized to distribute respondents as evenly as possible. SAS
version 8.1 was used for the statistical analysis (SAS Insti-
tute, Inc., Cary, NC).
2116 KIM AND KIM
RESULTS
General Characteristics
Table 1 summarizes the characteristics of the respondents.
There were overwhelmingly more women than men. Those
with no spouse outnumbered those with a spouse, and
overall educational attainment was low. There were similar
numbers of Buddhists, Christians, and those with no religion.
The average number of children was 4.6 and ranged from
0 to 12. For living arrangements, 24.4% lived with a spouse
only, and 25.1% lived alone. There were similar proportions
of nuclear and extended families. The largest proportion
(36.0%) of families had monthly incomes of less than
300,000 Korean won (1,200 Korean won 5 US$1 as of De-
cember 2003), and 3.7% received more than 2,100,000 won.
Slightly more people lived in rural areas than urban area.
More than two-thirds of respondents (71.1%) reported
their subjective health status as poor. In ADLs, 14.5% of
respondents reported limitations in one or two items out of
seven, and 4.9% reported more than three, but only 8.8%
were independent in all 10 IADL items, and more than half
were dependent in one or two items. On the MMSE, 33.4%
scored 20 to 23 points, and 17.2% scored fewer than 20
points. Respondents had an average of three chronic dis-
eases; 23.5% had more than five.
Intention to Use LTC Facilities
A total of 347 respondents expressed an intention to use
LTC facilities (18.8% of the total respondents). Table 2
shows that a stronger intention was related to younger age,
Christian religion, fewer children, lower family income, and
more chronic comorbidity.
DISCUSSION
As a whole, 18.8% of respondents intended to use LTC
facilities, which is probably lower than the proportions in
other countries that already have a higher percentage of
older people. Although direct comparison is not possible
because of different measurement, 28% of respondents in a
study conducted in the United States answered that they
would go to LTC facilities.16 It was also found that 53% of
Japanese Americans and 38% of Caucasian Americans re-
sponded positively to the idea of institutionalized LTC were
they to become demented.17 In spite of a lower level of
intention in Korea, this figure in the current study suggests
that many candidates for LTC facilities with the intention
are not able to use the service, meaning the current supply of
LTC facilities is insufficient. Immediate policy measures
should be instituted to meet the rapidly increasing demand
for LTC facilities in Korea.
Regarding the factors influencing the intention to use
LTC facilities, there are a few differences between this study
and previous studies conducted in countries with a higher
proportion of older adults. The common finding is that age,
family income, place of residence, number of children, and
education affect intention.
The influences of age and family income have varied
across studies. In one American study comparing Japanese
Americans with Caucasian Americans,17 age was related to
intention in patients with dementia and hip fracture, but
DECEMBER 2004VOL. 52, NO. 12 JAGS
positively correlated with one and negatively with the other.
Another study done in the United States showed that
younger age was related to intention, but it was not statis-
tically significant.17 In the current study, the younger the
respondents, the higher the intention. Younger people may
have a stronger intention because they are better informed
with respect to LTC and hence have a more positive attitude
toward such care. In the study comparing Japanese Amer-
icans with Caucasian Americans,17 family income was
found not to affect intention to enter LTC facilities, whereas
another American study showed that lower family income
was related to higher intention to use LTC facilities.13 The
current study also showed that intention increases when
family income is low, perhaps because disabled elders stay-
ing at home would increase the burden on families, partic-
ularly financial burden,13 but higher education level was
related to a stronger intention, as revealed in the previous
studies done in the United States.9,18 It is unclear why levels
of education and income showed opposite relationships
with intention, because it is usually the case that higher
income relates to higher education. It is possible that ed-
ucation is not an accurate measure for current income status
because a large proportion of the study participants had no
formal education. The intention to use LTC facilities was
found to differ according to place of residence, which is
consistent with a previous study performed in the United
States.18 That is, urban residents had a higher intention to
use LTC facilities than rural residents, which may be at-
tributable to the lower availability of facilities and more
traditional cultures in rural areas. Although women pre-
ferred home to facility care in a previous study,18 the result
in the current study was not statistically significant
According to Andersons model, factors related to need
more directly affect intention to use and actual use of LTC
services, but in the current study, there was no clear relation
between intention and physical or cognitive function. Al-
though intention was even weaker in respondents with
more severe cognitive impairments, this finding should be
carefully interpreted because the respondents might not
have been able to answer accurately. In comparison, a
higher level of comorbidity was consistently associated with
stronger intention to use LTC facilities. These findings sug-
gest that health needs are more important than functional
impairment with care requirements. As a result, many Ko-
rean elderly might poorly understand the role of and ne-
cessity for LTC facilitiesFcompared with health facilities.
In the current study, the presence of children rather
than spouses affected intention to use. In previous studies,
having no spouse was a critical factor in intention to use
LTC facilities,9,11,13,17 although children were also an im-
portant family resource,18 but in the current study, current
marital status was not a significant factor for intention, and
intention was significantly lower in respondents with more
children. This result suggests that Korean elderly people are
more dependent on their children for LTC.
An extended family, meaning living with children and
grandchildren, has been assumed to be an important family
resource, because until recently the extended family struc-
ture has been preferred in Korean society, and according to
the analysis of the current study, the rate of extended family
is still 37.5%, but the results of the current study show that
elderly people living with an extended family have only a
JAGS DECEMBER 2004VOL. 52, NO. 12 OLDER KOREANS ATTITUDES TOWARD LTC FACILITIES 2117

Table 1. Characteristics of the 1,850 Participants Table 1. (Contd.)

Intention to Use Long- Intention to Use Long-
Term Care Facility Term Care Facility

Positive Negative Positive Negative

Variable n (%) Total Variable n (%) Total

Total 347 (18.8) 1,503 (81.2) 1,850 (100.0) 12 60 (17.3) 208 (13.8) 268 (14.5)
Age 37 23 (6.6) 68 (4.5) 91 (4.9)
6569 119 (34.3) 406 (27.0) 525 (28.4) Limitations in instrumental activities of daily living, n
7074 105 (30.2) 407 (27.1) 512 (27.7) None 35 (10.1) 127 (8.5) 162 (8.8)
7579 71 (20.5) 378 (25.1) 449 (24.3) 12 187 (53.9) 812 (54.0) 999 (54.0)
80 52 (15.0) 312 (20.8) 364 (19.7) 35 79 (22.8) 378 (25.1) 457 (24.7)
Sex 610 46 (13.3) 186 (12.4) 232 (12.5)
Female 262 (75.5) 1,210 (80.5) 1,472 (79.6) Mini-Mental Status Examination score
Male 85 (24.5) 293 (19.5) 378 (20.4) 2430 195 (56.2) 675 (44.9) 870 (47.0)
Marital status 2023 106 (30.5) 512 (34.1) 618 (33.4)
Married 132 (38.0) 588 (39.1) 720 (38.9) 019 37 (10.7) 281 (18.7) 318 (17.2)
Bereaved/divorced 215 (62.0) 915 (60.9) 1,130 (61.1) Unknown 9 (2.6) 35 (2.3) 44 (2.4)
Schooling (years) Chronic comorbidities, n
0 218 (62.8) 1,071 (71.3) 1,289 (69.7) 0 13 (3.7) 90 (6.0) 103 (5.6)
16 106 (30.6) 381 (25.3) 487 (26.3) 12 100 (28.8) 599 (39.8) 699 (37.8)
7 23 (6.6) 51 (3.4) 74 (4.0) 34 129 (37.2) 484 (32.2) 613 (33.1)
Religion 5 105 (30.3) 330 (22.0) 435 (23.5)
None 115 (33.1) 540 (35.9) 655 (35.4) 
1,200 Korean won 5 1US$ (as of December 2003).
Buddhism 118 (34.0) 585 (38.9) 703 (38.0)
Christianity/ 110 (31.7) 339 (22.6) 449 (24.3)
Catholicism marginally lower level of intention to use LTC. In contrast
Others 4 (1.2) 39 (2.6) 43 (2.3) to this, the result that the number of children is a stronger
Children, n factor influencing intention implies that children are still
0 26 (7.5) 28 (1.9) 54 (2.9) expected to be responsible for the LTC of their parents,
12 67 (19.3) 156 (10.4) 223 (12.1) regardless of whether they live with an extended family.
34 106 (30.6) 456 (30.3) 562 (30.4) Korea differs from Western countries in having a rel-
56 114 (32.8) 598 (39.8) 712 (38.5) ative balance of different religious beliefs: Buddhism, Chris-
7 34 (9.8) 265 (17.6) 299 (16.1) tianity, and no religion. Religion was assumed to be an
Living arrangement important predisposing factor for intention. As expected,
Alone 117 (33.7) 347 (23.1) 464 (25.1) respondents following a Western religion such as Christi-
With spouse only 89 (25.7) 362 (24.1) 451 (24.4) anity had a higher intention to use LTC facilities than those
With children 118 (34.0) 709 (47.2) 827 (44.7) following no religion or Buddhism. In fact, traditional
With others 23 (6.6) 85 (5.7) 108 (5.8) Confucianism strongly influences many Koreans with no
Family type religion and even those following Buddhism; this could be
Nuclear 139 (40.1) 546 (36.4) 685 (37.0) contrasted with nontraditional and recently imported reli-
Extended 91 (26.2) 602 (40.1) 693 (37.5) gions such as Christianity. Consequently, Western religions
Others 117 (33.7) 355 (23.6) 472 (25.5) seem to be strongly related to more a westernized way of
Monthly family income (Korean won) thinking, resulting in a more generous attitude toward in-
o300,000 167 (48.1) 498 (33.1) 665 (36.0) stitutionalized LTC that departs from traditional family
300,000699,999 87 (25.1) 394 (26.2) 481 (26.0) centered care.
700,0001,099,999 40 (11.5) 218 (14.5) 258 (13.9) This study has some limitations. First, the intention to
1,100,0002,099,999 36 (10.4) 264 (17.6) 300 (16.2) use LTC facilities cannot be validated by assessing actual
2,100,000 9 (2.6) 60 (4.0) 69 (3.7) use of services. This limitation comes from the lack of LTC
Unknown 8 (2.3) 69 (4.6) 77 (4.2) facilities. As a result, in this study, intention should be in-
Place of residence terpreted as only one of the major factors determining use
Rural 139 (40.1) 866 (57.6) 1,005 (54.3) of LTC facilities. Another limitation comes from the low
Urban 208 (59.9) 637 (42.4) 845 (45.7) availability of LTC facilities in Korea. Many elderly people
Self-rated health
do not have sufficient information on LTC, because LTC
Good 34 (9.8) 224 (14.9) 258 (14.0)
provided by a nonfamily member is still unpopular and
Fair 45 (13.0) 230 (15.3) 275 (14.9)
underdeveloped. Inaccurate information may influence in-
Poor 267 (76.9) 1,049 (69.8) 1,316 (71.1)
tention, probably resulting in an underestimation thereof.
Unknown 1 (0.3) 0 (0.0) 1 (0.0)
Another investigation of residents of LTC facilities could
Limitations in activities of daily living, n
partly resolve these limitations, but residents are not rep-
None 264 (76.1) 1,227 (81.6) 1,491 (80.6)
resentative of the entire elderly population because most of
2118 KIM AND KIM DECEMBER 2004VOL. 52, NO. 12 JAGS

the residents are poor people subsidized by the government

Table 2. Result of the Multiple Logistic Regression of the
or wealthy people who are able to afford the large out-of-
Factors Affecting Intention to Use Long-Term Care Facil-
pocket payments.
ities
In spite of these limitations, quantifying the intention to
Odds 95% Confidence use LTC facilities is useful for the planning of LTC services.
Factor Ratio Interval Moreover, at the stage of developing such facilities it is
critical to forecast future demand for them, and intention
Predisposing should be considered as an important factor influencing the
Age actual use of services. In this regard, the results of this study
o75 1 are a meaningful starting point for efficient resource allo-
75 0.72 0.550.95 cation of LTC facilities in Korea.
Sex
Female 1
Male 1.16 0.791.71 CONCLUSION
Marital status With the rapid industrialization of Korea, the intention to
Widowed/divorced 1 use LTC facilities is showing a transitional tendency away
Married 0.80 0.571.11 from a focus on the traditional family and toward a non-
Education, years traditional way of caregiving. Compared with westernized
0 1 countries, the intention to use LTC facilities rate is still rel-
16 1.38 0.991.90 atively low in Korea. The influence of the extended family is
7 1.75 0.933.28 not as great as expected, but children continue to be re-
Religion garded as the main resources for LTC. The significance of
None 1 children is also reflected in the rather weak position of
Buddhism 0.98 0.711.35 spouses in the decision. A religion (Christianity) that is rel-
Christianity/Catholicism 1.44 1.032.02 atively new to Korea has a positive effect on intention to use
Other 0.53 0.181.57 LTC facilities, suggesting that the use of LTC facilities is
Enabling strongly related to tradition in terms of culture.
Children, n Korean society is rapidly becoming westernized. The
01 1 changes in the environment of LTC resulting from the rapid
24 0.49w 0.320.74 industrialization over more than 3 decades are also re-
5 0.36w 0.240.54 markable: prolongation of life, increased participation in
Family type the labor market by young women, and changes in family
Nuclear 1 structure. Consequently, the need for institutionalized LTC
Extended 0.70 0.491.00 is likely to increase, although the traditional mode of pro-
Family income (won) viding LTC by family members is still playing a major role.
o1,100,000 1 Therefore, it will be necessary to monitor the intention of
1,100,000 0.53w 0.350.80
the elderly population to use LTC facilities and to react with
Place of residence
appropriate measures as their needs change.
Rural 1
Urban 1.87w 1.412.49
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