Introduction

Six years have passed since Kaigo Hoken (the mandatory public long-term care social insurance system) was implemented in Japan in April 2000. According to Campbell and Ikegami (2003), the basic tenets of Kaigo Hoken are large scale in the coverage of services, universalism, and social insurance. One of the major changes regarding the provision of services under Kaigo Hoken was a shift from sochi (services assigned by the government) to keiyaku (services for which older people and their families privately contract). As a result, unlike with some of the public welfare services, a stigma is no longer associated with services provided through Kaigo Hoken in theory; therefore, older people have become consumers of the services. That is, older people now can choose the services they like. It is quite a new concept that older people can be viewed as “service consumers” (Fujisaki, 1997) in the social welfare field in Japan.

It is believed that as Kaigo Hoken further develops, this new idea of regarding older people as service consumers will become more accepted, making it much easier for older Japanese people to use services. It has been reported, however, that 23.6% of the older people who are entitled to in-home services under Kaigo Hoken do not utilize any service at all (Kourei shakai hakusyo, 2002). Moreover, it has been reported that although the level of usage of in-home services increased in the first two years of Kaigo Hoken, people living at home use only about half of the services to which they are entitled (Campbell & Ikegami, 2003).

According to Campbell and Ikegami (2003), four major problems moved Japanese policy makers to introduce Kaigo Hoken. These were: (a) the rapid growth of the older population, (b) the decline in traditional sources of care, (c) fiscal strains in maintaining such health and social programs as the medical insurance program, and (d) changes in people’s values (e.g., daughters-in-law are no longer automatically assumed to provide care for their in-laws, and it is becoming more acceptable to seek outside help).

Traditionally, it has generally been a rule among Japanese people that care in old age would be provided in the multigenerational household by the daughter-in-law (yome), the wife of either the oldest son or the co-residing son who is deemed to be the successor (Campbell & Ingersoll-Dayton, 2000; Jenike, 2003; Traphagan, 2003). If no male child is present in the household, it is the oldest daughter who must provide care to her frail parents. Also, it is typical that the child destined to care for the older generation will also inherit his or her parents’ property, become the head of the household, and continue the family line (Jenike, 2003; Traphagan, 1998, 2003). Traphagan (2003) further noted that providing care through co-residence to older parents was not only “a transaction related to inheritance and succession, but also has moral content” (p. 209). That is, a child has a moral responsibility to care for older parents via co-residence, and he or she who fulfills this responsibility is regarded as a good child (ko-ko musuko/ko-ko musume; Kinoshita & Kiefer, 1992; Traphagan, 2003). Hashimoto (1996) labeled this Japanese filial family support in old age as “structured protection” (p. 145), and this description makes good sense.

Brown (2003) reported that the meanings of asking for outside help with regard to care for the aged are twofold: (a) the failure of an older person to secure his or her foregone future, and (b) the failure of younger generations in the family to care for their older parents. On the significance of different caregivers, Sodei (1998) observed that if the person who provides care is the spouse or a daughter, reciprocity or attachment must be the motivation, whereas if the daughter-in-law is the caregiver, her motivation must be to fulfill her social obligation of assuming the role of a caregiver for her older parents-in-law and to meet the social expectation of being a good daughter-in-law.

This traditional patriarchal family arrangement is called ie, but this system was legally abolished after World War II. Although some researchers have reported that the traditional care support system has been losing its effectiveness (Kinoshita & Kiefer, 1992; Maeda, 2000), others contend that ie (in which caring for elderly parents is institutionalized) remains intact in many parts of the country even today (Campbell & Ingersoll-Dayton, 2000; Traphagan, 2003). Traphagan (2000a) further argued that people tend to underestimate the power that ie has over family members, contending that it is powerful enough to make family members return home to the rural countryside. It is the traditional ie, along with children’s moral obligation for providing care to frail parents, that creates the dynamics of the use of health and social welfare services for older people and their family members and that makes these dynamics very complex. For example, Jenike (2003) reported that some of the obstacles that a yome encounters when seeking caregiving help from outside sources include her apprehension about not being able to fulfill her familial obligation, as well as her husband’s, in-laws’, and/or elderly parents’ objections to her asking for outside help. This latter concern has been emphasized by other researchers (Campbell & Ingersoll-Dayton, 2000).

A tremendous amount of research has been conducted with regard to Japanese people’s attitudes toward the use of health and social welfare services and the factors that are associated with actual service utilization (The Japan Institute of Labour, 1990; Maeda, 1997, 1998; Matsubara, Nariyuki, Kitamura, & Koyano, 2000; Momose & Asahara, 1996; Okamoto, 1989; Sawada, 1996; Shimizu, 1982; Sugisawa, 2001; Sugisawa, Asakura, Sonoda, & Maeda, 1993; Takahashi, 1988; Takatorige, et al., 1990; Takemura, Hashimoto, & Koyano, 1995; Tokyo Metropolitan Research Institute, 1996; Wakabayashi, 1998; Yamada et al., 1997; Yamazaki, 1987). For example, it has been reported that the factors related to older people’s social welfare service utilization include having children to ask for care, older couple’s health status, old age (70 years or older), and low income (Takahashi, 1988). It has also been suggested that if the child to ask for care were the oldest son, then older people neither utilized services nor wanted to utilize them. Furthermore, other studies found that the major factors associated with the use of short-stay and day services were health status of caregivers, incontinence, and social support availability (Wakabayashi, 1998).

Additionally, it has been reported that some of the correlates to negative attitudes toward in-home care services were having a spouse, living with child(ren), having a low health status, and being of male gender, and that the correlates to positive attitudes toward service utilization included not living with child(ren), having a higher annual income, and knowing about the services (Yamada et al., 1997). At the same time, many research findings show that older people will not use services despite their critical needs and that older people and family members would feel ashamed of using health and welfare services (Asahara & Momose, 1995; Maeda, 1997, 1998; Sawada, 1996; Shimizu, 1982; Wakabayashi, 1998; Yamada et al., 1997).

Shimizu (1982, p. 13) reported that, of 179 caregivers for older people with a disability who needed home help services, 86 did not use these services despite their need to use them. The reasons caregivers gave for not using the services included “being reluctant to accept the notion of strangers coming into the house” (26.7%), “not wanting to be accused by family members and relatives” (8.1%), “not wanting to ask for help from the government” (5.8%), “finding the services insufficient to make them worthwhile” (3.5%), “not wanting to be accused by the older persons and his/her spouse” (3.5%), and “being worried about how neighbors might view him or her” (2.3%). Furthermore, Sawada (1996, pp. 227–228) reported that the “existence of strong ie-system and Sekentei, (a tendency to overly emphasize the importance of maintaining the family’s ‘face,’ which in turn would result in decreases in the use of services) is one of the major obstacles to family members’ service utilization.”

In addition, research conducted in Kyushu concerning the enrollment in home help services among middle- and old-aged people found that about 60% of 501 respondents said, “It is our right to enroll in these services and thus, we will do so with dignity,” but 28% of the respondents said, “It is a shame to receive the services and so we will stick with the practice of taking care of ourselves within the family.” Furthermore, 12% said, “We privately hire home-helpers to avoid psychological distress” (Maeda, 1997, p.122). Another study revealed that the stronger the older people’s sekentei, the more reluctant they would be to use health, welfare, and nursing care services (Momose & Asahara, 1996).

These research findings clearly show that many Japanese people and their family members still believe in the traditional notion of who should be responsible for caregiving in the family. A newspaper article recently reported that because of the strong influence of the idea that caregivers should be yomes, service utilization through Kaigo Hoken had not increased as much as had been expected (Ito, 2000). Furthermore, it was reported that the Saitama prefecture conducted research (N = 4,302) and found that the reasons people gave for not using Kaigo Hoken included “as for now, caregiving can be managed by family members” (49%), followed by “the older person needing the nursing care is hospitalized” (25%), “older people’s distaste in using nursing care services” (19%), “we do not want strangers coming into our house” (12%), and “family members do not want us to use these services” (7%)(Silver Sangyo Shinbun, 2002, p.14). Sugisawa (2001) reported research findings based on a random sample of older people drawn from one of the 23 wards in Tokyo. He found that being male, living with someone, and having family members and/or elders who held the notion that family members should care for older parents were related to the non-use of nursing care services.

In summary, the factors that affect service utilization among older people and their family members include not only their socioeconomic characteristics (e.g., gender, living arrangement, income) and health status (caregiver’s as well as older person’s), but also their social and psychological makeups—including their attitudes toward service utilization (i.e., sekentei), their social support network, and the extent of information they have on the services. Although a great deal of research has been conducted in Japan regarding people’s attitudes toward service utilization and the factors relating to the extent of actual service use, as was mentioned earlier, no study has been done on a nationally representative sample of older people.

Materials and Methods

Data

The data used in the study came from the first wave of the Nihon University Japanese Longitudinal Study of Aging (NUJLSOA), conducted in November 1999 (and again in March 2000 for those people who had been unable to respond to the initial survey). The NUJLSOA survey was conducted to examine a wide range of health-related issues among older people, and questions on older people’s attitudes toward using services were included in the questionnaire to obtain firsthand information. We were part of this survey team.

A multistage sampling method was used to draw 6,700 persons, and, using a structured survey questionnaire, face-to-face interviews were conducted by trained interviewers from a survey firm. People who were 75 years old and older were over-sampled in this survey to ensure a more detailed analysis of the oldest-old population. Although the total number of respondents was 4,997 including proxy respondents (response rate of 74.6%), responses from only 4,391 self-respondents were used for the present study. Weights were computed to represent the national population of older people aged 65 and older.

Measures

There were two questions regarding attitudes toward the use of services in the NUJLSOA survey. Respondents were asked to rate their level of reluctance to use home help services and day services respectively on a four-point scale: Very reluctant, Reluctant, Not so reluctant, Not reluctant at all, and Don’t know. The answers “Very reluctant” and “Reluctant” were coded as 1 (reluctant), and the answers “Not so reluctant” and “Not reluctant at all” were coded as 0 (not reluctant) in the analysis. Answers of “Don’t know” were excluded from the analysis. Those who answered “Very reluctant” or “Reluctant” were asked to choose the reason that best matched what they felt.

The following six choices, which were created by using answers from a pre-test questionnaire, were included as reasons for reluctance to use home help services: (a) Concerns about strangers coming into the house, (b) Having to clean the house before home helpers come, (c) Worrying if they can get along with home helpers, (d) Distaste for using welfare services, (e) Other, and (f) Don’t know. The following five choices were included as reasons for reluctance to use day services: (a) Fear of having to go to a strange place, (b) Inconvenient means of transportation and the length of time needed to get there, (c) Distaste for using welfare services, (d) Other, and (e) Don’t know.

The sociodemographic characteristics of the elders as collected in the study included age, gender, marital status, living arrangement, educational level, income, and occupation. Other factors that may affect the attitudes toward using services and that were used in the study were: (a) owning a house, (b) having caregiving experience, (c) having experience using home help services/day services, (d) participating in social activities, (e) having difficulties with seven activities of daily living (ADLs; including bathing, dressing, eating, moving, walking, going outside, and toileting), (f) having difficulties with seven instrumental ADL s (IADLs; including preparing one’s own meal, shopping for personal items, managing money, making phone calls, cleaning the house, going out by bus or train, and taking medication), (g) having knowledge of six selected nursing care services (the “Info” variable), and (h) agreeing with five selected statements about traditional Japanese values (the “Conserve” variable).

With regard to the Conserve variable, eight value-related questions were asked, and then principal components analysis was conducted in order to group the responses into a smaller group of correlated variables. Five of the eight variables, which loaded highly on a particular factor in a factor structure, were selected to create the Conserve variable. The factor appears to be related to the extent of conservativeness of the elder, hence the name Conserve variable. Five statements on which the Conserve variable was based were: (a) “It is the children’s duty to care for elderly parents,” (b) “Men should work, and women should stay home,” (c) “It is the eldest son’s duty to care for his parents,” (d) “The family name should be preserved even by an adopted son,” and (e) “Family graves should be passed on to future generations.” The remaining three statements were omitted from the analysis. For the five statements, the answers of “Agree” were coded as 1, and answers of “Disagree” were coded as 0. By adding up the individual scores, the Conserve variable made a total score that ranged from 0 to 5.

Analyses

We used three statistical methods in this study to test the nature of the relationships for each variable. First, χ 2 tests were used to test the nature of relationships between two dependent variables (i.e., feeling reluctant about using home help services and feeling reluctant about using day services) and the categorical sociodemographic variables. Second, to test the extent of bivariate associations between the dependent and independent variables in interval scale, we computed Pearson’s correlation coefficients. Finally, we used logistic regression model (forward) to identify the factors that affect older people’s feelings of reluctance about using nursing care services.

Results

Respondents’ characteristics

The sociodemographic characteristics of the respondents are shown in Table I. We applied weights to compute frequency distributions. As shown in Table I, the mean age of the respondents was 73 years old, which is slightly lower than the mean age of Japanese people who are 65 years of age and older. This difference is probably the result of the fact that those who were unable to be interviewed on their own power tended to be older than other respondents. Female respondents composed 56% of respondents, and two thirds of the respondents were married. Approximately 60% of respondents had less than a high school education, and about 87% of respondents had some sort of income. Approximately 13% of respondents lived alone, and about 26% lived with a yome. About 40% of respondents had worked their entire lives in salaried positions (e.g., office and factory workers).

Table I Socio-demographic Characteristics of the Respondents (N = 4,391)
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Descriptive analyses

Figure 1 shows the descriptive analyses for the responses regarding feelings of reluctance about using home help and day services. As is shown on the far left in Fig. 1, 53.6% of the respondents reported not being reluctant to use home help services, and 46.4% reported being reluctant. With regard to gender ratios, the proportion of female responses was higher in the reluctant category (63.0%) than in the not-reluctant category (49.4%). With regard to the use of day services, 75.5% of the respondents reported not being reluctant to use day services, and 24.5% reported being reluctant. Women consisted of 53.6% of the not-reluctant respondents and 62.5% of the reluctant respondents.

Fig. 1
figure 1

Proportion of older people who feel reluctant about using home help services and day services.

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Table II summarizes frequencies for the reasons the respondents felt reluctant about using home help services and day services. The most frequently mentioned reason for respondents’ reluctance to use home help services was concerns about strangers coming into the house, which was cited by 75.6% of respondents. This was followed by fear that family caregivers cannot get along with home helpers (11.8%), having to clean the house before home helpers come (5.4%), distaste for using welfare services (4.7%), and other reasons (2.5%). The most frequently mentioned reason for respondents’ reluctance to use day services was because of their fear of having to go to a strange place, which was cited by 73.9% of respondents. This was followed by distaste for using welfare services (12.4%), an inconvenient means of transportation and the length of time needed to get there (6.9%), and other reasons (6.8%).

Table II Reasons for Feeling Reluctant About Using Home Help Services and Day Services
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Bivariate analyses

Table III summarizes the results of χ 2 tests and Pearson’s r, which analyzed correlations between the dependent variable (feeling reluctant about using home help services) and several categorical and continuous variables. Statistically significant relationships existed between being reluctant to use home help services and some sociodemographic variables. Being female rather than male, not being married rather than being married, having child(ren) rather than not having child(ren), living in urban areas rather than living in rural areas, not having income rather than having income, and not having experience in using home help services rather than having experience in using the services were more likely to be associated with feeling reluctant about using home help services. Also, people with less information about services were more likely than people with more information about the services to feel reluctant about using home help services.

Table III Bivariate Analyses of Feeling Reluctant About Using Home Help Services
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Table IV summarizes the results of χ 2 tests and Pearson’s r, which analyzed correlations between the dependent variable (feeling reluctant about using day services) and several categorical and continuous variables. Statistically significant relationships existed between feeling reluctant about using day services and some sociodemographic variables. Being female rather than male, not being married rather than being married, living alone rather than living with others, having child(ren) rather than not having child(ren), living in urban areas rather than living in rural areas, not having experience in using day services rather than having experience in using the services, and not participating in any kind of social activity rather than participating in some sort of social activity were more likely to be associated with feeling reluctant about using day services. Also, people who were older, had more IADL difficulties, and knew less about services were more likely to feel reluctant about using day services than those who were younger, had fewer IADL difficulties, and knew more about services.

Table IV Bivariate Analyses of Feeling Reluctant About Using Day Services
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Logistic regression analyses

Table V shows the results of two logistic regressions; regressions of two variables (feeling reluctant about using home help services and feeling reluctant about using day services) on various socioeconomic and other variables, including age, gender, marital status, living arrangement, educational level, income status, regional area of residence, house ownership status, availability of child(ren) who could be counted on as caregivers, caregiving experience, experience in using home help/day services, participation in social activities, health status, knowledge about nursing care services, and extent of conservativeness.

Table V Significant Logistic Regression Coefficients and Odds Ratios on Feeling Reluctant About Using Home Help Services and Using Day Services
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With regard to factors related to older people’s reluctance to use home help services, results indicate that the likelihood of feeling reluctant about using home help services was significantly different among women than among men; the odds of women being reluctant doubled compared with men. Moreover, the results indicate that the likelihood of feeling reluctant about using home help services was significantly different among older people living in urban areas than among older people living in rural areas. That is, older people living in urban areas had approximately 1.3-times higher odds of feeling reluctant about using home help services than people living in rural areas.

Also, it was found that the likelihood of feeling reluctant about using home help services was significantly different among older people who had had experience in using the services than among older people who had no such experience; older people with experience in using services had 0.53-times lower odds than older people without that experience of feeling reluctant about using home help services.

Certain variables were not found to be statistically significant and did not affect the odds ratio of feeling reluctant about using home help services. These variables were: the respondent’s age, marital status, living arrangement, availability of child(ren) who could be counted on as caregivers, educational level, income status, house ownership status, caregiving experience, participation in social activities, health status, knowledge about nursing care services, and extent of conservativeness.

With regard to factors related to older people’s reluctance to use day services, the results indicate that the likelihood of feeling reluctant about using day services was significantly different among women than among men; women had 1.9-times higher odds of feeling reluctant about using day services than males.

Also, the results show that the likelihood of feeling reluctant about using day services was significantly different among older people living in urban areas than among older people living in rural areas. That is, older people living in urban areas had 1.6-times higher odds of feeling reluctant about using day services than older people living in rural areas.

Additionally, it was found that the likelihood of feeling reluctant about using day services was significantly different among older people with income than among older people without any income; older people with income had 1.7-times higher odds of feeling reluctant about using day service than older people without any income. By the same token, the results suggest that the likelihood of feeling reluctant about using day services was significantly different among older people who had had experience in using the services than among older people who had no such experience; older people with experience in using services had 0.16-times lower odds than older people without that experience of feeling reluctant about using day services.

Furthermore, older people with caregiving experience had 0.7-times lower odds than older people without that experience of feeling reluctant about using day services. Additionally, older people who participated in social activities showed 0.7-times lower odds than older people who did not participate in social activities of feeling reluctant about using day services. The variables marital status, living arrangement, availability of child(ren) who could be counted on as caregivers, educational level, house ownership status, health status, knowledge about nursing care services, and extent of conservativeness were not found to be statistically significant in affecting older people’s feelings about using day services one way or another.

Discussion

The effect of being female was the strongest among the variables examined for reluctance to use home help services. This finding contradicts a research outcome from a similar study. Yamada et al. (1997) suggested that gender was not statistically associated with attitudes toward the use of home help services. The discrepancy between these two research findings, however, needs to be interpreted with great caution. First, the sampling frame (one ward in Tokyo) and sample size (1,600 cases) of Yamada and colleagues’ study were different from those of the present study. Second, the research questions that Yamada and colleagues used were different from those that we used in the present study.

The reasons that women have higher odds than men of feeling reluctant about using home help services are: (a) Across the country, people have been accustomed to the cultural norm, which emphasizes that caregiving is the role of women. Hence, men feel less reluctant about seeking outside help; and (b) Because more women than men are responsible for house-keeping tasks, women would feel more possessive than men about things inside the house and would not like to be intruded on by an outsider. Moreover, the average age of the female respondents in this study was 73.4 years old, meaning they were educated in the pre-war period. Therefore, it is likely that their responses were influenced by the traditional cultural norm that care should be provided within a family and that outside help should not be sought. The tendency of women to show higher odds of reluctance than men was also found with regard to their use of day services.

Additionally, older people living in urban areas showed higher odds than those living in rural areas of feeling reluctant about using home help services. This finding was consistent with the findings of Yamazaki (1987), who also found that older people in urban areas showed greater reluctance to use day services. The question to ask is why. Is it because older people living in urban areas may appreciate being independent and self-sufficient more than those who are living in rural areas? On the basis of an ethnographic study in Japan, Jenike (2003) reported that in urban Tokyo, the foundation of intergenerational contracts upon which the obligations of the yome were built has started to fade away. If this is true, it would make great sense that older people in urban areas would try to be more self-sufficient and, thus, would be reluctant to use formal services. Furthermore, older people with income showed higher odds of feeling reluctant about using day services. This is probably because they would not like to be dependent on government services and would like to be more self-reliant by using their own resources. However, this finding contradicts results of previous research (Yamada et al., 1997), and further research is needed.

Older people without experience in using home help services showed higher odds of feeling reluctant about using them. This is quite reasonable, because people tend to be more cautious about doing things that they do not know well. It is also quite normal that once people become accustomed to these services and know what to expect from them, they will feel less reluctant about utilizing the services. This finding is consistent with other research outcomes (Takahashi, 1988; Yamada et al., 1997). For example, it has been reported that “knowing information about the services” is associated with positive attitudes toward the use of home help services (Yamada). The tendency of older people without experience in using home help services to show higher odds of reluctance was found with regard to their use of day services, as well. Having experience in using home help services reduced the odds of feeling reluctant about using these same services by half, whereas having experience in using day services reduced the odds of feeling reluctant about using these same services by nearly one fifth (16/100). That is, the effect of having experience in using day services on reducing the extent of reluctance with regard to service use was greater than that of having experience in using home help services. It is difficult to determine exactly why this is the case. In any event, these research findings point out the importance of strengthening outreach programs targeted at older people and their families. It is clear that information about nursing care services should be disseminated effectively to those who can really benefit from them.

Although we expected that older people living with children would show higher odds of feeling reluctant about using both home help and day services, the findings of this study did not support that expectation. The findings, however, need to be re-examined, as they contradict some previous research (Takahashi, 1988; Yamada et al., 1997). Does Japan’s traditional family-care system no longer function effectively, as some ethnographic studies suggest (Jenike, 2003; Kinoshita & Kiefer, 1992; Traphagan, 2003)? Additionally, although this study found that the older person’s conservativeness was not related to feelings of reluctance about using nursing care services, further research is needed to investigate whether the definition of conservativeness used in this study makes good sense.

Having caregiving experience reduced the odds of feeling reluctant about using day services. Older people who have experience providing care should know that caregiving is a difficult job and might not want to burden other people when they need care themselves. Jenike (2003) also observed this phenomenon among older people in her ethnographic study conducted in Japan. Additionally, older people who participate in social activities showed lower odds of feeling reluctant about using day services. It is probable that such older people must be well exposed to the outside world and, thus, would have access to information about services. It is reasonable to assume that once people know more about what day services are like, the odds of their feeling reluctant about using them would decrease. This implies that participation in social activities would give older people not only enjoyment and fulfillment but also opportunities for increasing their knowledge of various topics.

This study has generated new information about older people’s attitudes toward care services, based on data from a nationally representative sample of older people in Japan just prior to the start of Kaigo Hoken. It was found that, as of November 1999, 46.4% of survey respondents felt reluctant about using home help services, and 24.5% felt reluctant about using day services. Among those who felt reluctant, 60% were female for both home help and day services. Moreover, as it had been assumed, the extent of reluctance felt by older people differed with regard to the kind of care service; more older people showed reluctance to use home help services than day services. The most frequently cited reason by the respondents who felt reluctant about using home help services was concerns about strangers coming into the house (75.6%). Researchers have to be a little cautious when interpreting these findings, however. They do not necessarily mean that people who feel reluctant about using care services do not actually use the services. It is probably true that many of these people will still use the services when necessary despite their feelings about using them.

Yet these findings offer some important implications for professional service providers. Because women tend to outlive men and also tend to live alone in their later years, they often need care services. It is extremely critical that service providers make an effort to understand older women’s attitudes toward and feelings about using services and try to help reduce their psychological burden. On a similar note, it must not be forgotten that some older people mentioned that their reason for feeling reluctant about using care services was that they “dislik[ed] using any welfare service.”

There are some limitations to the present study that must be noted here. The study would have been able to generate more information if the specific reasons behind the respondents’ feelings about the use of services had been explored. Some of the questions that should have been asked pertain to older people’s attitudes toward family caregiving, relationships between older people and family members, and relationships among family members and relatives.

In conclusion, given the rapid growth of the proportion of older people in the Japanese population, the increase in women’s labor force participation, the increase in the incidence of Alzheimer’s disease and other biomedical forms of dementia (Traphagan, 2000b), and shifts in cultural and social values in family caregiving that Japanese people are now experiencing, the importance of caregiving will become more pronounced in the not-too-distant future. As Hashimoto (2000) stated, a new definition of security in old age will have to be developed. Although recent research has found that Kaigo Hoken will not facilitate the breakdown of the long-practiced tradition of family caregiving (Sugisawa, 2001), other research findings contend that Kaigo Hoken will facilitate the increase of older people’s service utilization (Campbell & Ikegami, 2003; Maeda, 2000). Accordingly, it is reasonable to predict that as Kaigo Hoken, an entitlement social insurance program, further matures, the attitudes of older people and their family members toward public service utilization will change markedly and their psychological obstacles will diminish. As a result, it is quite possible that women will no longer be expected to bear the total responsibility for providing care for their older parents. Thus, the real success of Kaigo Hoken should be measured by the extent to which older people and their family members use services without any reluctance and feel satisfied with the services that they select.