Hisanori Ishikawa

イシカワ ヒサノリ

石川 久展

石川, 久展

イシカワ, ヒサノリ

Ishikawa, Hisanori

Japan Lutheran College and Theological Seminary Institutional Repository / ルーテルリポジトリ

113The Attitudes towards Formal and Informal Care among Japanese Young Old in Rural Japan■ 国際学会招待シンポジューム講演 ■ ＊This paper was orally presented to one of the Invited Sympo-sia at the 58th Annual National Congress of the GerontologicalSociety of America held in Orlando, Florida, U.S.A., October10-17, 2005.＊＊ 石川久展　　 ルーテル学院大学教授The Attitudes towards Formal and Informal Care among Japanese Young-Old in Rural Japan＊Ishikawa,  Hisanori＊＊1. Purpose of the studyJapan has been aging rapidly for these two decadesand Japan is now one of the most aged populations inthe world with the percentage of aged 65 and overamong the whole population totaling more than 20%in 2005.  This rapid aging of Japan will continue to2030, and it is estimated that the percentage of olderpeople will be 30 percent in 2030.  Because of thisrapid aging, Japan will confront many problems suchas an increase in the very old, a decrease in the num-ber of children, a decline in family care and mutualhelp in the community, and a lack of social welfareor care services for the disabled and cognitive im-paired elderly.The Public Long-Term Care Insurance Program(LTCI) in Japan started in April 2000 in order to copewith the rapid aging and rapid increase in care needs.Five years have passed since it started.  A reformedLTCI will start in April, 2006.  We have found throughthis five-year experience of LTCI that formal care suchas LTCI and other services based on the welfare lawsmight not be sufficient to cope with all needs of physi-cal, instrumental, and psycho-social care.  The ap-propriate combination of formal care and informalcare has become a critical policy issue to meet careneeds after the implementation of the Public Long-term Care Insurance in Japan.Thus, there are two purposes for this study; one isto describe the characteristics of attitudes toward carepreferences for informal and formal care, as well ascare responsibility among young-old people aged 60to 74 in a rural area in Japan.  The other is to try toestablish a framework for an appropriate combina-tion of formal care and informal care.2. MethodsDefinitions of informal care and formal care in thisstudy are as follows;1) Formal Care:Formal care is care provided by governments, for-profit and/or non-profit organizations on the basis oftax, social insurance and/or market mechanisms.2) Informal Care:Informal care is unpaid care provided by familymembers, relatives, friends, neighbors, and volun-teers.114ルーテル学院研究紀要　No.40　20063) SampleA total of 1059 young-old people aged 60 through74, who were not in need of care, were selected byrandom sampling from the Resident Registries inChino City, Nagano Prefecture, Japan. Data wereobtained by interviewing and a total of 810 interviewswere completed successfully.  This survey was con-ducted from November through December, 2003.4) Measurement(1) Social Networks:Social networks were measured by two sub-scalesof which consisted of three items.  One sub-scale wasnetwork size (the number of close relatives, friends,and neighbors), and the other sub-scale was contactfrequency (contact with close relatives, friends, andneighbors).(2)Anxiety toward Care in Old AgeThere were three items regarding anxiety towardcare in Old Age.  Each item was measured by a di-chotomous scale of “yes” or “no”.  Items were anxi-ety toward family care, expense of care, and institu-tionalization.(3)Expectations toward Formal CareThere were four items regarding formal care; in-home care services such as bathing, feeding, andtoileting, home help services such as cooking, clean-ing, and shopping, assisted housing services includ-ing group home for dementia, and institutional ser-vices such as nursing homes.(4)Attitude toward Care ResponsibilityThere were four items with regard to attitude to-ward care responsibility to evaluate children’s respon-sibility for their parents.  Each item was measured bya 4-point scale; strongly agree, somewhat agree,somewhat disagree, and strongly disagree.  We usedadded scores of the four items as a scale score (Aver-age Score=9.25, Cronbach α =.817).  These fourquestions are as follows;(1) Children must take care of their parents whenthey need physical care.(2) Elder sons or heirs must take care of their par-ents.(3) Children must live together with their parents.(4) Daughters-in-law must take care of their par-ents.(5)Care Preference:Care preferences for formal care and informal careconsisted of 4 items and each item was ranked on a7-point scale (Average Score=16.6, Cronbach α=.897).  This is a linear scale in which the higher thescore, the greater the preference for formal care andlower the score, the greater the preference for infor-mal care.  These items included: care for physicalneeds such as feeding, bathing, and toileting, help withdaily living tasks such as cooking, laundry, and soforth, emotional support (advice), and social contacts(called “koekake”).3. ResultsSample characteristics are shown in Table1.Table 1    Sample CharacteristicsGenderMale 48.9% (396)Female 51.5% (414)Total 100.0% (N=810)EmploymentEmployed 49.1% (395)Not Employed 50.9% (409)Total 100.0% (N=804)Age60-64 36.2% (293)65-69 31.9% (258)40-49 32.0% (259)Total 100.0% (N=810)SpouseHave Spouse 83.6% (674)None 16.3% (132)Total 100.0% (N=806)ChildrenHave Children 92.0% (745)None 8.0% (65)Total 100.0% (N=810)EducationJunior-High 34.9% (281)High-school 58.9% (474)College 6.2% (50)Total 100.0% (N=805)115The Attitudes towards Formal and Informal Care among Japanese Young Old in Rural JapanFirst of all, we evaluated the respondent’s partici-pation in activities.  The proportion of participationin community activities such as volunteer activitiesand community center activities in the past one yearwas 23%.  This is higher than other Japanese young-old people.  Based on the 5th International Compara-tive Study, participation in social welfare activitiesaged 60 and over was 8.7%. We asked about the pos-sibility of volunteer activities in the future.  The per-centage of future volunteer activities was 43.8% andabout half of the respondents had positive attitudestoward voluntary activities.The next question was anxiety toward care in oldage.  There were three items: anxiety toward not hav-ing family care, expenses for care and institutional-ization.  The proportion of family care was 51%, ex-pense of Care was 64%, and institutionalization was74%.  Three-fourth of respondents might be afraid ofliving in institutions when they need care in the fu-ture.With regard to social networks, the proportion ofco-residence was 46.7%, and half of the young-oldlived together with their parents.  This is almost thesame result as other surveys in Japan.  The mean ofthe number of children was 1.94 and which is alsothe same result as for others.  Table 2 shows the simplecharacteristics of social networks of the respondents.There are two network scales; one is network size ofrelatives, neighbors, and friends and the other is fre-quency of contact with relatives, neighbors, andfriends.  Relative network size is larger than othertwo resources.  On the other hand, contact with neigh-bors is more frequent than others.Table 3   Results of One-way ANOVA:Male 10.6 7.1Female 10.7 8.0Social NetworksSize Contact ****P<.01 *p<.0560-64 10.5 7.265-69 10.6 7.670-74 10.9 7.8Network Score By Age CategorySize Contact ****P<.01 *p<.05Junior-high 9.7 7.1High-school 11.2 7.9College 10.8 6.7Network Score By EducationSize** Contact ****P<.01 *p<.05Rural area 11.2 7.8Old town area 11.1 8.0New town area 9.7 7.1Mixed area 9.7 6.4Network Score By Ares CharacteristicsSize** Contact ****P<.01 *p<.05Living with spouse 10.9 7.5Living alone 13.7 5.3Divorced 8.5 7.4Widowed 10.3 8.1Never married 5.9 6.2Network Score By Marital StatusSize** Contact ***P<.01 *p<.05Table  2    Characteristics of Social NetworksNetwork SizeNumber RelativesNoneOneTwoThreeFour to SixSeven to nineMore Than TenAverage Score4.2% (34)5.0% (40)12.8%(103)12.1% (98)31.8%(256)11.2% (90)23.0%(185)Neighbors12.5%(101)7.8% (63)13.3%(107)17.7%(143)23.2%(187)7.2% (58)18.2%(147)Friends12.7%(102)6.0% (48)12.1% (97)17.4%(140)19.8%(159)4.0% (32)28.0%(225)Frequency of ContactFrequency RelativesOne to a fewtimes a year　One to a fewtimes a month　One time a week　Few times a week　Almost everyday　Average Score21.4%(165)　41.0%(316)　18.4%(142)　11.2% (86)　7.9% (61)Neighbors2.3% (16)　17.3%(122)　22.7%(160)　30.2% (21)　27.5%(194)Friends25.1%(176)　39.9%(280)　18.5%(130)　11.3% (79)　5.1% (36)3.88 3.26 3.502.43 3.63 2.31116ルーテル学院研究紀要　No.40　2006The next table (Table3) shows the results of a one-way ANOVA of each sub-scale of social networks bysocio-demographic variables such as gender, age cat-egory, education, marital status, and area character-istics.  With regard to gender difference, the resultsshow a significant difference in social contacts be-tween male and female.  The mean score for malewas 7.1 and 8.0 for female.  The results of maritalstatus, education, and area characteristics were alsosignificant.  Respondents who lived alone or werewidowed had larger network sizes than others.  Wid-owed had significantly more frequents contacts thanothers.  Respondents who graduated from high-schools had significantly larger network sizes andmore frequent contacts than the other groups.  Peoplewho lived in rural areas and old town areas had sig-nificantly larger networks and more frequent contactsthan other areas.   People who lived in rural areas andold town areas resided for a long time in this city andthis might indicate that the traditional Japanese closesociety remains in these areas.The next topic concerned care responsibility.  Wetried to examine changes in attitudes toward care re-sponsibility, which is part of the traditional Japaneseculture (children must take care of their parents; as itwere “filial piety”).  Here, 67% of respondents thoughtthat they had to take care of their parents when inneed of physical care.  On the other hand, 35% thoughtelder sons had to take care of them.  One-third of therespondents answered that daughters-in-law had totake care of them.  These results might show a changein traditional family care in Japan.    .The results of a one-way ANOVA for care responsi-bility by socio-demographic variables are shown inTable 4.  There was a significant gender difference.Males tend to take more care responsibility than fe-males.  We determined the linear relationships amongage cohorts.  The older the respondents are, the morethey tend to take responsibility for their parents.  Withregard to differences in living area, people who livedin new town area were more likely not to think thatthey had to assume care in the future than other areas.The final analyses concerned care preference.  AsI mentioned earlier, formal care services might notbe enough to cope with increasing needs for care inJapan.  To deal with this problem, we have tostrengthen informal care from families, relatives,neighbors, and volunteers.  We also have to try toexamine the optimal combination of formal and in-formal care.  This is a kind of pilot study to try toevaluate this appropriate combination.The question was : Which combination of infor-mal care and formal care do you prefer?1) Physical care: In need of physical care such asbathing, feeding, and toileting.2) Help with daily tasks: In need of help of dailyTable 4: Resuls of One-way ANOVA of CareResponsibilityHighLaw18.314.6Care Responsibility Care Preference ****p<0.05;**p<0.01;***p<0.001.MaleFemale9.88.8Gender Care Responsibility ****p<0.05;**p<0.01;***p<0.001.60-64 yrs old65-69 yrs old70-74 yrs old8.99.49.6Age Category Care Responsibility **p<0.05;**p<0.01;***p<0.001.Junior-HighHigh-SchoolCollege and University9.59.28.6Education Care Responsibility *p<0.05;**p<0.01;***p<0.001.Rural Area Old Town AreaNew Town AreaMixed Area9.69.38.59.8Area Characteristics Care Responsibility ***p<0.05;**p<0.01;***p<0.001.117The Attitudes towards Formal and Informal Care among Japanese Young Old in Rural Japantasks such as cooking, cleaning, and shopping.3) Advice when needed: In need of advice formaking decisions.4) Social Contacts: Social contacts such as casualvisits, and telephoning.The scale of care preference was on Figure 1.  It isa 7-point scale.  The lower the, the greater the prefer-ence for informal care and vice-versa.Figure 1　Scale for Care Preference(7-point scale)1. All Informal Care 2. Almost All Informal Care4. Half Informal Care    Half Formal Care3. Informal Care with Some    Formal Care5. Formal Care with Some    Informal Care 6. Almost All Formal Care 7. All Formal Care　私的なケア　　　公的なケア 　私的なケア　　　公的なケア 　私的なケア　　　公的なケア 　私的なケア　　　公的なケア 　私的なケア　　　公的なケア 　私的なケア　　　公的なケア 　私的なケア　　　公的なケア These results implicated that respondents tendedto prefer formal care for professional or instrumentalneeds and, on the other hand, they were more likelyto select informal care for emotional and autonomouscare needs.The Table 5 shows the results of a one-wayANOVA for care preference by socio_demographicvariables such as gender, age category, education,marital status, and area characteristics.  There was nosignificant gender difference.  With regard to age cat-egory, respondents under 70 years old were morelikely to prefer formal care than those aged 70 andmore.  People who lived alone or were unmarried tendto prefer significantly more formal care than the othercategories .  Finally, respondents who lived in new118ルーテル学院研究紀要　No.40　2006town areas, which means they are free from tradi-tional Japanese society, were more likely to preferformal care than other areas.Summary of the results and discussion1. First of all, young-old people in Chino-City didconsiderable volunteer activities over the previ-ous one year compared with other Japanese young-old.  Their attitude toward future volunteer activi-ties also seems to be positive.  It is reported thatsocial activities are significantly related to socialisolation in old age and these activities are impor-tant to prevent them from requiring care.2. Most of the respondents expect formal care for in-home services and home-help services.  These ser-vices are mainly provided by professionals.  Thismight indicate that the young-old would like tohave formal services by professionals when in needof heavy care and have informal care when in needof light or instrumental care.3. Many investigators have reported that social net-works have a strong impact on mortality and men-tal and physical health.  The results of a one-wayANOVA showed that the differences in area char-acteristics such as rural, old town, new town, andmixed areas was significant and that people wholived in rural and old town areas had larger net-works and more frequent contacts than other ar-eas.  They might still have traditional Japaneserelationships.  This result is important.  It is saidin Japan that many traditional communities havecollapsed in urban areas because of westerniza-tion and we need to rebuild our communities for awelfare society.4. Five years have passed since LTCI started in 2000.The purpose of the LTCI was to cope with the rapidincrease in care needs and make personal care(children must take care of their parents) social(society has to be in charge of care).  The children’sresponsibility for taking care of their parents willbe lighter than five years ago and it will also changetheir attitudes toward family care.  However, theresults of our survey showed that two-third of therespondents still think that children have to takecare of their parents in need of physical care.  Theredoesn’t seem to be a big change in attitudes to-ward care.  On the other hand, the number of ser-vice utilization and service users has been dramati-cally increasing for five years.  Attitudes towardcare might be changing more slowly than actualservice use.Males are more likely to take care responsibilitythan females in the results of a one-way ANOVA.With regard to differences in living areas, peoplewho lived in new town areas were more likely notTable 5: Resuls of One-way ANOVA of carePreferenceMaleFemale16.616.7Gender Care Preference*p<0.05;**p<0.01;***p<0.001.60-64 yrs old65-69 yrs old70-74 yrs old16.917.615.4Age Category Care Preference ****p<0.05;**p<0.01;***p<0.001.Junior-HighHigh-SchoolCollege and University16.616.617.5Education Care Preference*p<0.05;**p<0.01;***p<0.001.Rural Area Old Town AreaNew Town AreaMixed Area16.415.619.215.0Area Characteristics Care Preference ****p<0.05;**p<0.01;***p<0.001.Living with SpouseLiving AloneDivorcedWidowedUnmarried16.521.017.916.123.3Marital Status Care Preference ***p<0.05;**p<0.01;***p<0.001.119The Attitudes towards Formal and Informal Care among Japanese Young Old in Rural Japanto think that they have to assume care in   futurethan other areas.5. Formal care and informal care have respectivestrengths and weaknesses. Formal care is appro-priate for securing a national or local minimumlevel of care and providing professional and in-strumental care.  On the other hand, informal careis more appropriate for emotional and autonomouscare but weak in providing professional care.  AsProfessor Shimizu at Sophia University suggestedan optimal combination of formal care and infor-mal care for the elderly will ultimately become aninfluential model for elderly care in Japan and theworld in the 21st century.  We tried to evaluate thecombination of formal care and informal care us-ing our own scales.  There results indicated thatrespondents tended to prefer formal care for physi-cal or instrumental care needs and prefer informalcare for emotional and social contact needs.  Thismight suggest that we had better enhance infor-mal care such as families, relatives, neighbors, andvolunteers to meet their psycho-social care needsin next decade.  The result of a one-way ANOVAshowed that people who are living in new townarea, which means they are free from traditionalJapanese society were more likely to prefer to for-mal care than other areas.  This might suggest thata combination of formal care and informal carewill differ by living areas.Future TasksThere were two purposes for this study: one wasto describe the characteristics of attitudes toward carepreferences for informal and formal fare, as well ascare responsibility among young-old people aged 60to 74 in a rural area in Japan.  The other was to try toestablish a framework for an appropriate combina-tion of formal care and informal care.There are limited empirical studies on this topicin Japan.  This study is a kind of pilot study.  There-fore, there are some tasks which need to be examinedin the future.  First of all, as there are limited studieson this topic in Japan, more studies will be needed.Secondly, with regard to sampling, our study was con-ducted in a very limited geographic area, Chino City,Nagano Prefecture.  We need to have and analyzenation_wide samples in order to generalize the find-ings.The final task is the lack of scales and uniformityin the selection of items of social networks, care pref-erence, and so forth.  Inadequate measurements re-main a major problem with studies concerning theimpact of social relationships, as suggested by manyresearchers.  We need to examine the validity and re-liability of our own scale in further studies.It is hoped that this study’s attempt to determinean optimal combination of formal care and informalcare for the elderly will ultimately become an influ-ential model for elderly care.

The Attitudes towards Formal and Informal Care among Japanese Young-Old in Rural Japan

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The Attitudes towards Formal and Informal Care among Japanese Young-Old in Rural Japan

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