The Knowing–Doing Gap in Advance Directives in Asian Americans: The Role of Education and Acculturation

Abstract

Objectives:

The purposes of the present study were (1) to explore the completion rate of advance directives (ADs) in a sample of Asian Americans and (2) to examine the direct and moderating effects of knowledge of AD, education, and acculturation in predicting AD completion. Education and acculturation were conceptualized as moderators in the link between knowledge and completion of ADs.

Methods:

Using data from 2609 participants in the 2015 Asian American Quality of Life survey (aged 18-98), logistic regression analyses on AD completion were conducted, testing both direct and moderating effects.

Results:

The overall AD completion rate in sample was about 12%. The AD knowledge and acculturation independently predicted AD completion. No direct effect of education was found; however, it interacted with AD knowledge. The AD knowledge was more likely to be translated into completion in the group with higher education.

Conclusions:

The AD completion rate observed in the present sample of Asian Americans was much lower than that of the US general population (26%-36%). The interactive role of education helps to explain the gap between AD knowledge and completion and suggests intervention strategies.

Keywords

advance directives Asian Americans

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References

Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press; 2014.

Morhaim

Pollack

. End-of-life care issues: a personal, economic, public policy, and public health crisis. Am J Public Health. 2013;1039(6):e8–e10.

Emanuel

Barry

Stoeckle

Ettelson

Emanuel

. Advance directives for medical care—a case for greater use. N Engl J Med. 1991;324(13):889–895.

Bischoff

Sudore

Miao

Boscardin

Smith

. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc. 2013;61(2):209–214.

Brinkman-Stoppelenburg

Rietjens

JAC

van der Heide

. The effects of advance care planning on end-of-life care: a systematic review. J Palliat Med. 2014;28(8):1000–1025.

American Association of Retired Persons (AARP). AARP Bulletin Poll: Getting Ready to Go: Executive Summary [on-line]. Washington, DC: American Association of Retired Persons; 2008. Web site. http://assets.aarp.org/rgcenter/il/getting_ready.pdf. Accessed May 3, 2016.

Pew Research Center. More Americans discussing -and planning- end-of-life treatment. Web site. http://www.people-press.org/files/legacy-pdf/226.pdf. Published January 2006. Accessed May 10, 2016.

Rao

Andersen

Lin

Laux

. Completion of advance directives among U.S. consumers. Am J Prev Med. 2014;46(1):65–70.

Pollack

Morhaim

Williams

. The public’s perspectives on advance directives: implications for state legislative and regulatory policy. Health Policy. 2010;96(1):57–63.

10.

Dobbs

Park

Jang

Meng

. Awareness and completion of advance directives in older Korean-American adults. J Am Geriatr Soc. 2015;63(3):565–570.

11.

Berkman

. Advance directives among Korean American older adults: knowledge, attitudes, and behavior. J Gerontol Soc Work. 2012;55(6):484–502.

12.

Lee

Hinderer

Friedmann

. Engaging Chinese American adults in advance care planning. J Gerontol Nurs. 2015;41(8):17–25.

13.

Doorenbos

Nies

. The use of advance directives in a population of Asian Indian Hindus. J Transcult Nurs. 2003;14(1):17–24.

14.

McAdam

Stotts

Padilla

Puntillo

. Attitudes of critically ill Filipino patients and their families towards advance directives. Am J Crit Care. 2005;14(1):17–25.

15.

Pew Research Center. The rise of Asian Americans. Web site. http://www.pewsocialtrends.org/files/2013/04/Asian-Americans-new-full-report-04-2013.pdf. Updated April 4, 2013. Accessed May 3, 2016

16.

Hoeffel

Rastogi

Kim

Shahid

. The Asian population: 2010. U.S. Census Bureau. Web site. https://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf. Published March 2012. Accessed May 3, 2016.

17.

Glanz

Rimer

Viswanath

, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: John Wiley & Sons; 2008.

18.

Alano

Pekmezaris

Tai

. Factors influencing older adults to complete advance directives. Palliat Supp. 2010;8(3):267–275.

19.

Lee

. Completion of advance directives among low-income older adults: does race/ethnicity matter? Am J Hosp Palliat Care. 2014;31(3):247–253.

20.

Berry

. Conceptual approaches to acculturation. In Chun

Organista

Marin

, eds. Acculturation: Advances in Theory, Measurement, and Applied Research. Washington, DC: American Psychological Association; 2002:17–37.

21.

Chiriboga

. Some thoughts on the measurement of acculturation among Mexican American elders. Hisp J Behav Sci. 2004;26(3):274–292.

22.

Islam

Khan

Kwon

Jang

Trinh-Shevrin

. Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: historical challenges and potential solutions. J Health Care Poor Underserved. 2010;21(4):1354–1381.

23.

Lee

Cheng

. Reaching Asian Americans: sampling strategies and incentives. J Immigr Minor Health. 2006;8(3):245–250.

24.

Jang

Yoon

Park

Chiriboga

. The health vulnerability of immigrants with limited English proficiency: a study of older Korean Americans. J Am Geriatr Soc. IN PRESS.

25.

Tay

Davison

Jin

Kiat

. Education and executive function mediate engagement in advance care planning in early cognitive impairment. J Am Med Dir Assoc. 2015;16(11):957–962.

26.

Caralis

Davis

Wright

Marcial

. The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. J Clin Ethics. 1993;4(2):155–165.