What Influences Utilization of Senior Citizen Centers? Evidence from the 2017 National Survey of Older Koreans

A cross-sectional analytical study was conducted using secondary data from the 2017 National Survey of Older Koreans. Descriptive statistics were used to determine utilization patterns; and chi-square test, bivariate and multivariate logistic regression analyses were conducted at a 5% significance level to determine the factors associated with senior citizen center utilization.


Conclusion
Socio-demographic factors, life satisfaction, and health status influence utilization of the senior citizen centers. Therefore, the government's community-based care strategy should take these factors into consideration.

Background
Korea is moving toward becoming a super-aged society. In 2017, more than 14% of Koreans were aged 65 or older. National survey of older Koreans reported that 57.7% of senior citizens were desirous of living out their remaining years in their own homes [1].
Accordingly, the Korean government has recently created a blueprint for expanding care services to seniors in their homes by 2025. This is being considered an alternative to medical institutions or nursing homes for seniors and dependent persons [2]. The community-based home health care project has shown improved service implementation for older adults [3].
The majority of the elderly evaluate their quality of life on the basis of social contacts, dependency, health, material circumstances, and social comparisons [4]. Health-related quality of life (HRQoL) is an important component of healthy aging. Aging does not have to influence quality of life negatively; rather, a long period of good quality of life in old age is possible. Therefore, quality of life improvement should be promoted in the elderly care program [4]. A previous study found that participants older than 80, males, and those with poor self-rated health were most likely to use primary care services or traditional Korean services [5]. This demonstrates that the elderly prefer community-based services. In addition, as the needs of the elderly population are numerous and complex, wellcoordinated health services integrated with social welfare services are recommended [6].
Population aging, changing disease patterns and the increase in the need for chronic disease management have led to an increased interest in the use of community-based care. According to a study conducted in a British city, understanding the determinants of the use of both statutory and private home care services is important because of the increasing numbers of elderly people in the population and the policy of allowing older people to remain in their own homes [7].
A study concluded that there is overreliance on inpatient care and unmet health care needs among long-term care users as a result of weak gatekeeping by primary care and a lack of effective coordination between health care and long-term care in Korea [8]. The prevalence of unmet health care needs in Korean elderly was found to be 17.4%, and people with visual, hearing, or memory impairment were more likely than others to report unmet health care needs [9]. With the rapid growth of the elderly population, it has been recommended that the government utilize existing senior centers for the implementation of the long-term care prevention program.
In Korea, senior citizen centers and senior welfare centers are the main venues for seniors to engage in leisure and cultural activities [1]. In addition, these centers, which are widely known in the community, offer programs and services that promote health and prevent disease [10]. Evidence from previous research involving comparisons with non-users shows that participation in senior center activities influences mental and physical health [10]. To cope with the burden of the health care needs of Korea's aging population, rather than investing in new infrastructure, strengthening existing senior centers might be a cost-effective and sustainable strategy. However, as the utilization of senior citizen centers can be associated with several factors, this study aimed to assess utilization patterns and the role of socio-demographic variables, life satisfaction, functional ability, and health status using data from the 2017 National Survey of Older Koreans, conducted by the Korea Institute for Health and Social Affairs. Persons or community center for the elderly in the last one year?" The response "yes" was coded "1" and "no" "0."

Independent variables
Sociodemographic variables: Questions on gender, age, marital status, number of family members, residential area, and employment status were asked to determine the sociodemographic situation.
Number of diseases present: The questions covered 32 chronic diseases, including the option of "others," that subjects had been suffering from for more than three months after diagnosis. To calculate the prevalence of multiple diseases, all items were summed up and categorized as "no disease", "one disease", "two diseases," and "more than two diseases."

Result
At 42.5%, about three-fourth of the study population was male. The proportion of the population that lived alone was 23.6%. Regarding age, 32.4% were in the age group of 65 to 69 years and 21.7% were 80 and above. Of the total population, 30.3% were employed.
Of the total population, 22.7% had used a senior citizen centers at least once in the last 12 months. The average number of visits in a week was 3.91 (SD ±2.24). Among those who visited senior citizen centers, the main reason for doing so was a desire for company (63.2%), followed by 25.1% who visited in order to get dinner, and 5.4% who wished to engage in a health promotion activity. Of the total population, 81% were very satisfied or satisfied with the services provided. Only 3.1% of the population was not satisfied. Of the total population, 36.0% intended to use these services in the future. Regarding elderly welfare centers, only 9.1% of the subjects used these services in a year ( Table 2).
Of the total population, 59.1% had been diagnosed with hypertension, which was the main chronic disease. The second, third, and fourth most common chronic diseases were hyperlipidemia, lumbago and sciatica, and diabetes at 29.2%, 23.9%, and 23.3%, respectively. Of the study population, 13.0% were diagnosed as having osteoporosis. Of the total, only 10.3% were disease free and 51.4% population had multiple health problems (Table 3).
There was a significant association between gender and senior citizen center utilization among females in contrast to males. Age group, marital status, educational level, residence, number of family members, and number of diseases present were also significantly associated with senior citizen center utilization. There was a significant association between life satisfaction variables and community center utilization (Table 4).
In the adjusted logistic regression model, being female, increasing age of elderly, no education or lower education, being widow/widowers, having current employment and living in rural area were significantly associated with increased odds of senior citizen center utilization. Regarding life satisfaction and health status, satisfaction with financial condition, satisfaction with leisure and culture, satisfaction with friends and society, functional ability and presence of multiple diseases were also significantly associated with higher likelihood of senior citizen center utilization. In the crude analysis, most of the chronic conditions had higher odds of visiting the center except being diagnosed with cancer. However, these variables were not included in the adjusted model due to the significant and high correlation with the number of disease. The factors of model 1 and model 2 predicted 32% and 37% of the utilization of the center (Table 5).

Discussion
This study aimed to determine senior citizen center utilization and the associated factors based on data from the 2017 National Survey of Older Koreans. Utilization was found to be relatively low, and the associated factors were socio-demographic variables, life satisfaction, and health status. Of the total study population, 22.7% had visited a senior citizen centers or community center for the elderly in the last 12 months, with an average of 3.9 visits per week. Regarding social welfare centers, 9.1% had visited at least once in the last 12 months, with an average of 2.5 visits a week. In Korea, senior citizen centers and senior welfare centers are the main venues where seniors engage in leisure and cultural activities [1]. Desiring company was the foremost reason for visiting senior citizen centers (63.2%), followed by the availability of meals (25%) and health programs (5.4%).
Thus, expanding the scope of senior citizen center to ensure better health and welfare might have a positive impact on the health of senior citizens.
Senior citizen center utilization was significantly associated with socio-demographic variables such as gender, age group, educational level, residential place, marital status, and employment status. There was a significant association between gender and senior citizen centers utilization, with females more likely to visit them. Another study conducted among older adults in Korea also found a significantly higher number of females to be using senior citizen centers [11]. Regarding education, there was a reverse association with the center utilization: the higher their level of education, the less likely subjects were to visit senior citizen centers. In contrast to the present results, a study by Kim et al. (2012) found a positive association between education and senior center utilization among older adults in Korea [11]. The present study also revealed that seniors involved in some form of employment had higher odds of the center utilization.
Family support and family relations appeared to be important factors affecting senior citizen center utilization. In Model 1, all married people including widows/widowers more likely to visit senior citizen centers than the unmarried. After adjusting the model with all explanatory variables in Model 2, the odds of visiting senior citizen centers were significantly higher among widows/widowers than the never married/separated/divorced. It was also evident that subjects with higher family support were more likely to visit senior citizen centers. Senior citizen center utilization in Korea is affected by support from family and friends [11]. People usually wish to be at home near death. Living alone, a lack of visits by relatives or acquaintances, dissatisfaction with the place of residence, and being fully dependent in daily activities were determined to be factors that increased the level of loneliness. Elderly people who are alone and dependent in activities of daily living should be monitored closely [12]. A survey conducted among adults in Alberta revealed that 70.8% preferred to be at home near death, 7.0% wished to be in a hospital, and 1.7% wanted to be in a nursing home [13]. The evidence also suggests that the home health care program is economical [14]. Now, home care nursing intervention programs customized to patients' family function and daily activities are required [15].
The ultimate goal of the government long term care insurance policy is to provide homeand facility-based support to seniors with geriatric diseases and dementia, as well as to reduce the support burden on other family members [16]. Good financial condition was highly associated with successful aging. The study suggests that the advancement of the As the study included data from the national survey among older Koreans, the findings may well represent the Korean population, however it has some limitations. First, due the unique socio-cultural context of Korean elderly population, the findings may not be applicable in other study settings where senior citizens centers are not conceptualized as they were in South Korea. Second, as the study was cross-sectional, causal inferential could not be made.

CONCLUSION
This study revealed that 22.7% of the elderly had visited a senior citizen center in the last 12 months and that more than 95% were satisfied with the services they had received.
Elderly females were 20% more likely to utilize a senior citizen enters as compared to males. The older the participants were, the more likely they were to visit a senior citizen centers. The odds of visiting senior centers were also higher among those with low educational levels. Residential area was also significantly associated with the odds of visiting a senior citizen center, with participants from eup meon bu 6.42 more likely than others to visit them. The employed elderly were 1.73 times more likely than the unemployed to visit a senior citizen center. Financial satisfaction, cultural satisfaction, and satisfaction with friends and society were also associated with increased odds of visiting a senior citizen center. Higher odds of senior citizen center utilization were observed for the elderly diagnosed with multiple diseases. Subjects who did not require help in performing daily activities were also more likely to visit a senior citizen center than those who did. This showed that being diagnosed with a disease, and especially so in the case of multiple diseases, led the elderly to visit a senior citizen center until they were unable to perform daily activities. Socio-demographic factors, life satisfaction, and health status affect community center utilization. Therefore, the governmental strategy of providing community-based care should take these factors into consideration.

Ethical approval and consent to participate
The data used in this study were collected by the Korea Institute for Health and Social Affairs as a part of the 2017 National Survey of Older Koreans. Therefore, independent ethical clearance for this study was not required. Consent for the use of data was obtained from Ministry of Health and Welfare.  Authors' contributions: BS conceptualized study design, did data analysis and prepared draft manuscript. GS contributed to access and manage the data, to design the study and to revise and interpret of the result. EN involved in the study design and critically revised the manuscript. All authors read and approved the manuscript.