Attitude Toward the Provision of Long-Term Care (ATPLTC)

Abstract

The Attitude Toward the Provision of Long-Term Care (ATPLTC) scale is a 26-item psychometric self-report instrument developed by Waldo C. Klein (1992) to evaluate individual and familial attitudes toward providing ongoing informal assistance to dependent family members across the lifespan, including frail older adults and individuals with developmental or physical disabilities. Emerging at the intersection of gerontology, family sociology, and clinical social work, the instrument gauges an individual’s normative commitment to familial caregiving versus reliance on formal institutionalization or state-sponsored welfare systems. The ATPLTC employs a 5-point Likert scale ranging from 1 (Strongly agree) to 5 (Strongly disagree), with 11 reverse-scored items designed to attenuate acquiescence bias. Psychometric evaluations across diverse populations demonstrate strong internal consistency, with Cronbach’s alpha coefficients typically ranging from .82 to .89 across validation and cross-cultural cohorts. Exploratory and confirmatory factor analyses indicate a multidimensional structure, highlighting central dimensions such as filial and parental moral obligation, perceived personal burden, comparative appraisal of institutional versus family care, and societal expectations regarding long-term caregiving. The scale serves as a vital diagnostic and predictive metric in clinical social work, family therapy, geriatric case management, and healthcare policy research, facilitating the assessment of caregiver preparedness, familial conflict, and institutional placement risks.

Keywords

Attitude Toward the Provision of Long-Term Care, ATPLTC, informal caregiving, filial responsibility, family caregiving, long-term care, institutionalization attitudes, gerontology psychometrics, caregiver burden, adult child caregiving

Authors

The Attitude Toward the Provision of Long-Term Care (ATPLTC) scale was conceptualized and psychometrically validated by Waldo C. Klein, Ph.D., MSW. Dr. Klein developed the instrument during his doctoral research at the University of Hawaii at Manoa and subsequently validated it within empirical studies published in social work and gerontological journals.

• Author: Waldo C. Klein, Ph.D., MSW
• Affiliation at Development: School of Social Work, University of Hawaii at Manoa, Honolulu, Hawaii, USA; subsequent academic appointments include the School of Social Work at the University of New England, Portland, Maine, USA.
• Primary Research Focus: Gerontological social work, informal caregiving dynamics, family support systems for frail older adults, health disparities, and psychometric measurement of familial care obligations.
• Historical Context: Dr. Klein created the scale to address an acute empirical deficit in the early 1990s: the lack of standardized, validated instruments capable of measuring multidimensional attitudes toward caregiving for disabled relatives of any age, moving beyond narrow, population-specific filial piety scales.

Purpose

The primary purpose of the Attitude Toward the Provision of Long-Term Care (ATPLTC) scale is to measure an individual’s underlying ideological beliefs, ethical commitments, and pragmatic expectations regarding the informal provision of long-term care to impaired family members. As demographic shifts produce aging populations worldwide and medical advancements extend the lifespans of individuals with developmental and physical impairments, the societal dependence on family units to serve as informal care providers has grown exponentially. The ATPLTC was engineered to address several distinct diagnostic, theoretical, and policy objectives:

From a clinical perspective, the ATPLTC provides healthcare practitioners, medical social workers, and clinical psychologists with a quantifiable measure of a caregiver’s internalized sense of duty versus perceived entrapment. When families face complex transitions—such as discharging a stroke-afflicted parent from an acute care facility or managing a young adult with severe neurodevelopmental delays—care planning frequently breaks down due to unspoken, conflicting ideological values among family members. Administering the ATPLTC allows clinicians to identify discordant expectations among adult siblings, detect underlying resistance or resentment toward care obligations, and proactively mitigate the risk of severe caregiver burden, psychological burnout, and potential elder or dependent neglect.

From a research and epidemiological perspective, the scale serves as a predictive instrument for health outcomes and health-seeking behaviors. Empirical investigations employ the ATPLTC to forecast which family systems are likely to delay institutionalization and manage prolonged functional dependence at home, versus those who view formal long-term care facilities as the superior or ethically preferable primary option. Furthermore, the scale enables cross-cultural and intergenerational researchers to assess how modernization, economic mobility, female workforce participation, and state welfare policies alter traditional norms of familial solidarity.

Psychological Construct

The construct assessed by the ATPLTC is the generalized normative attitude toward informal familial caregiving. Rather than measuring momentary situational stress or subjective burden in an ongoing caregiving role (constructs captured by instruments such as the Zarit Burden Interview), the ATPLTC captures deep-seated value orientations, belief systems, and socialized norms regarding the moral locus of care. This construct spans multiple interconnected psychological dimensions:

1. Moral and Familial Imperative (Normative Duty)

This core dimension evaluates the belief that family members have an inviolable moral, biological, and societal obligation to provide physical and emotional assistance to dependent kin. Reflected in items such as “Providing care to a disabled family member is a basic human responsibility” (Item 15) and “It is the responsibility of families to care for their disabled members” (Item 7), this component measures the internalization of altruistic kinship responsibilities. Individuals scoring high on this dimension view family caregiving not as an optional charity or an onerous imposition, but as a foundational pillar of societal continuity and personal character.

2. Acceptance of Personal Sacrifice

Providing long-term assistance often demands radical reorganization of an individual’s professional, economic, and domestic life. This dimension assesses the respondent’s willingness to subordinate career aspirations, leisure time, and financial security in favor of caregiving duties. Items addressing this construct include “People should be willing to quit their jobs in order to provide care to impaired family members” (Item 13) and “Families should rearrange their schedules in order to provide care to disabled family members” (Item 17). It contrasts selfless commitment with self-preservation priorities.

3. Perceived Equity and Fairness (Burden Appraisal)

This dimension taps into the latent resentment, cognitive appraisal of unfairness, and emotional cost associated with intensive caregiving. Formulated through reverse-scored statements such as “It is not fair that adult children should have to give up so much to care for frail elderly parents” (Item 1) and “Older family members who cannot bathe or dress themselves are an unfair burden to their children” (Item 25), this component identifies individuals who perceive physical dependence as an unjust imposition that damages the lives of younger family members.

4. Appraisal of Institutional vs. Home Care

An essential psychological facet of the ATPLTC is the comparative evaluation of formal institutional environments (such as nursing homes and assisted living facilities) versus informal domestic care. Items such as “Nursing homes or institutions can provide better care for disabled relatives than families” (Item 5) and “Family members who cannot bathe or dress themselves are better off in nursing homes or institutions” (Item 9) examine whether an individual considers institutional placement to be an act of abandonment or an ethically sound, professionally competent solution.

5. Fatalism and Futility

A smaller, critical dimension measures feelings of helplessness and perceived existential futility regarding chronic disability. Reflected in extreme statements such as “When people can no longer care for themselves, it would be better for them to die than to be dependent on family to provide care” (Item 21) and “Providing care for disabled family members at home is useless since most of them will end up in institutions or nursing homes anyway” (Item 18), this facet uncovers severe ideological aversion to prolonged physical dependency.

Theoretical Framework

The conceptual architecture of the ATPLTC is rooted in established theories across social psychology, sociology of the family, and gerontological systems theory.

1. The Theory of Intergenerational Solidarity

Formulated by Vern Bengtson and colleagues, the Intergenerational Solidarity Model posits that cohesion within family lineages operates along distinct structural, functional, affectual, and normative axes. The ATPLTC directly operationalizes normative solidarity—defined as the strength of commitment to family roles and mutual obligations across generations. According to Bengtson’s paradigm, normative solidarity serves as the cognitive blueprint that determines whether functional solidarity (the actual mobilization of financial, instrumental, and physical care) will manifest when a family member suffers cognitive or functional impairment.

2. Social Exchange Theory

Under Social Exchange Theory (developed by George Homans and Peter Blau), human social interactions are evaluated through a subjective cost-benefit calculus. In traditional family systems, caregiving to dependent elders is framed as a delayed reciprocity for parental investments made during childhood. The ATPLTC assesses the degree to which an individual views this exchange as an equitable social contract versus an asymmetric, economically disadvantageous burden. The scale captures whether adult children view filial obligations through generalized exchange (maintaining family honor and psychological reciprocity) or through direct cost paradigms where the physical, financial, and emotional costs exceed perceived rewards.

3. The Stress and Coping Paradigm in Caregiving

Grounded in the transactional stress model of Richard Lazarus and Susan Folkman, alongside Leonard Pearlin’s Caregiver Stress Model, the ATPLTC functions as an operationalization of primary cognitive appraisal. When faced with the functional decline of a parent or child, the individual’s baseline attitudes act as cognitive mediators. A prospective caregiver who holds favorable attitudes toward familial caregiving (high ATPLTC score) appraises daily assistance tasks as meaningful responsibilities, reducing threat perceptions. Conversely, an individual holding negative attitudes (low ATPLTC score) appraises the caregiving imperative as an unfair, catastrophic disruption, exacerbating chronic stress and secondary role strain.

Validity

Psychometric evaluations of the ATPLTC have established robust evidence supporting its construct, convergent, discriminant, and criterion-related validity across clinical and non-clinical samples.

Construct Validity

During the initial development of the scale, Klein (1992) demonstrated construct validity by administering the instrument to heterogeneous groups varying in their objective caregiving exposure and demographic backgrounds. Construct validity was confirmed through known-groups comparisons: individuals who had actively chosen home-based informal caregiving scored significantly higher on the ATPLTC compared to individuals who had opted for immediate nursing home placement for impaired relatives (p < .001). Furthermore, the scale demonstrated substantial sensitivity in differentiating between individuals with high vs. low general social support commitment.

Convergent and Concurrent Validity

Convergent validity has been established by correlating ATPLTC scores with validated instruments assessing filial responsibility, family cohesion, and caregiving orientation:

• Filial Obligation Scales: The ATPLTC exhibits moderate to strong positive correlations (r = .52 to .68, p < .001) with standardized measures of filial piety and familial obligation, such as the Filial Responsibility Scale.
• Family Cohesion: Positive correlations are consistently observed with the cohesion subscales of the Family Adaptability and Cohesion Evaluation Scales (FACES III), demonstrating that individuals from unified, emotionally integrated family systems hold significantly more favorable attitudes toward long-term care provision.
• Burden Prediction: Prospective longitudinal studies show that baseline ATPLTC scores correlate inversely with early-stage scores on the Zarit Burden Interview (ZBI; r = -.38 to -.46, p < .01), indicating that positive ideological attitudes buffer against early subjective caregiver distress.

Cross-Cultural and Clinical Validity

Cross-cultural adaptations have further validated the scale’s construct validity. For instance, Bastani, Ramezani, Lolati, and Haghani (2017) examined the psychometric properties of the ATPLTC among family caregivers of elderly individuals with psychiatric disorders. Their findings demonstrated that the instrument effectively captured variations in caregiver attitudes across chronic psychiatric conditions, showing that lower ATPLTC scores strongly predicted caregiver depression, expressed emotion, and heightened demand for state institutionalization.

Reliability

The ATPLTC demonstrates excellent reliability across diverse adult cohorts, clinical caregiving environments, and international research settings:

Internal Consistency

• Original Scale Validation: In Klein’s original 1992 psychometric investigation, the 26-item scale demonstrated high overall internal consistency, yielding a Cronbach’s alpha coefficient of .87 across the general sample.
• Subscale Consistency: The moral obligation and familial duty dimensions typically demonstrate alphas ranging from .81 to .86, whereas the burden appraisal and institutional comparison dimensions demonstrate coefficients between .74 and .82.
• Cross-Cultural Reliability: In the study conducted by Bastani et al. (2017) involving caregivers of older adults with chronic psychiatric illnesses, the instrument demonstrated an overall Cronbach’s alpha of .85, confirming that the scale retains strong item-total coherence when translated and applied within varied sociocultural settings.

Test-Retest Stability

Stability across time has been demonstrated over two- to four-week intervals among non-caregiving adult cohorts, yielding Pearson correlation coefficients ranging from r = .78 to .84. These findings confirm that while individual items may fluctuate with acute life crises, the core underlying construct reflects a stable ideological disposition rather than a transient emotional state.

Factor Analysis

The underlying dimensionality of the ATPLTC has been examined through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across multiple independent cohorts.

Exploratory Factor Analysis (EFA)

Initial principal components analysis with varimax and oblimin rotations performed by Klein (1992) revealed that the 26 items coalesce around four to five primary factors accounting for over 52% of the total variance:

• Factor 1: Moral and Social Obligation (Eigenvalue > 5.2): Accounting for the largest portion of variance, this factor encompasses items 3, 7, 8, 10, 14, 15, 16, 17, 19, and 26. Item factor loadings range from .54 to .78, capturing the belief in family caregiving as an essential social and ethical duty.
• Factor 2: Institutional Appraisal and Preference (Eigenvalue > 2.4): Defined by reverse-scored items such as 5, 9, 18, and 23. Loadings range from .48 to .71, evaluating whether institutions are perceived as more capable than family units.
• Factor 3: Personal Sacrifice and Unfair Burden (Eigenvalue > 1.8): Anchored by reverse-scored items 1, 11, 20, 22, and 25, alongside item 13. Loadings span .46 to .69, isolating the cognitive evaluation of physical and financial exhaustion.
• Factor 4: Caregiver Self-Efficacy and Competence (Eigenvalue > 1.3): Marked by items 4, 6, and 24, focusing on confidence in family capacity over formal providers.

Confirmatory Factor Analysis (CFA)

Subsequent psychometric modeling has tested both unidimensional and multidimensional models. While a single higher-order factor of “Generalized Pro-Familial Caregiving Orientation” is psychometrically viable for calculating a composite score, hierarchical four-factor and five-factor solutions demonstrate superior fit indices:

• Comparative Fit Index (CFI): .91 to .94
• Tucker-Lewis Index (TLI): .90 to .93
• Root Mean Square Error of Approximation (RMSEA): .048 to .058 (90% CI [.041, .065])
• Standardized Root Mean Square Residual (SRMR): .052

These structural equation metrics confirm that the ATPLTC captures distinct yet correlated facets of long-term caregiving ideology.

Instrument / Measurement Tool

The structural characteristics, administration protocols, and scoring parameters of the ATPLTC are organized as follows:

• Test Type: Standardized self-report rating scale / psychometric questionnaire.
• Target Population: Adult family caregivers, adult children of aging parents, parents of individuals with developmental disabilities, social work clients, and the general adult population.
• Format: Pen-and-paper or digital/computerized survey administration.
• Item Count: 26 statements.
• Administration Time: Approximately 10 to 15 minutes.
• Response Scale: 5-point Likert scale formatted as:
  • 1 = Strongly agree
  • 2 = Moderately agree
  • 3 = Neither agree nor disagree
  • 4 = Moderately disagree
  • 5 = Strongly disagree
• Reverse-Scored Items: Items 1, 5, 9, 11, 12, 18, 20, 21, 22, 23, and 25 are negatively worded and require reverse scoring.
• Scoring Procedures:
  • Standard Scoring Direction: Depending on the researcher’s analytical objective, items can be scored such that higher scores represent more favorable attitudes toward family-provided care, or lower scores represent more favorable attitudes.
  • Convention for Favorable Family Care Orientation (1 = Least Favorable, 5 = Most Favorable): To make higher scores reflect positive attitudes toward family caregiving, positively worded items (2, 3, 4, 6, 7, 8, 10, 13, 14, 15, 16, 17, 19, 24, 26) are inverted (1 becomes 5, 2 becomes 4, 3 remains 3, 4 becomes 2, 5 becomes 1), while reverse-scored items (1, 5, 9, 11, 12, 18, 20, 21, 22, 23, 25) retain their direct numeric values (where 5 = Strongly disagree with the anti-caregiving/burden statement, thus indicating pro-family care orientation).
  • Total Score Range: 26 to 130 points. Higher scores indicate strong normative endorsement of family caregiving, higher willingness to assume personal sacrifice, and skepticism toward institutionalization. Lower scores denote preference for institutional/governmental care, perceived unfairness of personal burden, and reluctance to assume informal caregiving tasks.

Permissions & Fee and Test Year

• Year of Initial Publication: 1992.
• Original Source: Klein, W. C. (1992). Measuring Caregiver Attitude Toward the Provision of Long-Term Care. Journal of Social Service Research, 16(3-4), 147–162.
• Sourcebook Compilation: Fischer, J., & Corcoran, K. J. (2007). Measures for Clinical Practice and Research: A Sourcebook (4th ed., Vol. 1, pp. 207–209). Oxford University Press.
• Copyright & Permissions: The scale was published in academic literature and sourcebooks intended for clinical and research practice. It is accessible for scholarly, educational, and non-commercial research purposes provided proper academic citation is given to the author and publisher. Commercial licensing, integration into proprietary healthcare software, or corporate usage requires formal permission from the copyright holder (Taylor & Francis / Haworth Press or Oxford University Press).
• Fee: Free for academic, non-funded research and clinical evaluation use via published sourcebooks and university repositories.

References

• Bastani, F., Ramezani, A., Lolati, H. A., & Haghani, H. (2017). Family caregivers’ attitude toward long-term care of elderly with psychiatric disorders and associated factors. Iranian Journal of Psychiatry and Behavioral Sciences, 11(1), e4010. https://doi.org/10.5812/ijpbs.4010
• Bengtson, V. L., & Roberts, R. E. (1991). Intergenerational solidarity in aging families: An example of formal theory construction. Journal of Marriage and the Family, 53(4), 856–870. https://doi.org/10.2307/352993
• Fischer, J., & Corcoran, K. J. (2007). Measures for clinical practice and research: A sourcebook (4th ed., Vol. 1, pp. 207–209). Oxford University Press.
• Klein, W. C. (1992). Measuring caregiver attitude toward the provision of long-term care. Journal of Social Service Research, 16(3-4), 147–162. https://doi.org/10.1300/J079v16n03_09
• Klein, W. C. (1991). Caregiver attitude toward the provision of long-term care (Doctoral dissertation, University of Hawaii at Manoa). ScholarSpace. https://scholarspace.manoa.hawaii.edu/items/22d56a29-0744-4860-9366-231aee89efc1
• Pearlin, L. I., Mullan, J. T., Semple, S. J., & Skaff, M. M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30(5), 583–594. https://doi.org/10.1093/geront/30.5.583

Items of the Scale