Willingness of older Korean-American adults to use hospice

Approaching neuro-palliative care with historically minoritized groups in the United States: A literature review and actionable recommendations

This review critically examines neuro-palliative care disparities in historically minoritized groups in the U.S., particularly in Asian, Black, and Latino communities. Addressing a gap in the 2022 American Academy of Neurology guidelines, this review synthesizes current literature and our clinical experiences as neurologists who identify as members of these communities in diverse care settings. We identify common barriers to palliative care access and acceptance, influenced by cultural heterogeneity, mistrust, and systemic disparities. The review offers targeted, actionable recommendations at the provider, healthcare system, and policy level to improve care and reduce disparities.

Centering intersectional breast cancer screening experiences among black, Latina, and white women: a qualitative analysis

Objective

Mammography screening guidelines in the United States highlight the importance of informing and involving women when making their breast cancer screening decisions. However, the complexity of interpreting and applying these population-level guidelines can contribute to patient burden. Patient-centered communication strategies can alleviate patient burden, but few consider perspectives from racially and ethnically marginalized populations. We examine diverse women's perspectives on screening to characterize patient-centered experiences.

Methods

We conducted 28 focus groups with 134 non-Latina Black (n = 51), non-Latina White (n = 39), and Latina (n = 44) participants. We coded participants' discussion of their screening influences. We used deductive and inductive qualitative methods to identify common themes.

Results

We identified three themes: (1) personal relationships with primary care providers, (2) potential impacts of cancer on families, and (3) interactions with medical systems. Most White participants described trusting physician relationships in contrast to perfunctory, surface-level relationships experienced by many Black participants; high costs of care prevented many Latina participants from accessing care (Theme 1). Diagnosis was a concern for most Black participants as it could burden family and most Latina participants as it could prevent them from maintaining family well-being (Theme 2). While many White participants had general ease in accessing and navigating healthcare, Latina participants were often held back by embarrassment-and Black participants frequently described disrespectful providers, false negatives, and unnecessary pain (Theme 3).

Conclusion

Cultural and structural factors appeared to influence participants' approaches to breast cancer screening. Structural barriers may counteract culturally salient beliefs, especially among Black and Latina participants. We suggest patient-centered communication interventions be culturally adjusted and paired with structural changes (e.g., policy, insurance coverage, material resources) to reflect women's nuanced values and intersectional social contexts.

Hospice Knowledge, Attitudes, and Preference among Older Chinese Immigrants in the United States

Racial disparities in hospice use are a longstanding concern in the U.S. Asian Americans are among the least likely to receive hospice care and to be included in studies on this topic. This study examined the knowledge, attitudes, and preferences related to hospice care among older Chinese immigrants and associated factors. A sample of 262 Chinese immigrants age 60+ was recruited from six older adult centers in NYC. In-person interviews were conducted in Mandarin and Cantonese. Non-English-speaking older Chinese immigrants had very limited knowledge about hospice care. Only 26% of respondents had heard of hospice, and a few could correctly define any components. After receiving a comprehensive definition of hospice care, study participants expressed a positive attitude and a strong willingness to use hospice if near the end of life. Notably, some respondents still held misconceptions about hospice and were less positive in their attitude and preference for hospice care. These findings underscore the necessity for clear and accessible information about hospice among this population throughout the trajectory from good health to end of life. Further research is needed to identify the range of factors that influence the attitudes and preferences of older Chinese immigrants toward hospice care.

Factors related to advance directives completion among cancer patients: a systematic review

INTRODUCTION

Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients.

METHODS

A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior.

RESULTS

Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics".

CONCLUSION

The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

The informal discussion of advance care planning among Chinese older adults: Do education and social media use matter?

This study aimed to examine and compare the associations between education, social media use, and advance care planning (ACP) discussion among Chinese older adults in mainland China (Wuhan), Taiwan (Taichung), and the United States (Honolulu). Community-dwelling older adults (≥ 55) were recruited from 2017 to 2018. The ACP discussion rate in Wuhan, Taichung, and Honolulu were 15.2 %, 19.2 %, and 31.3 %, respectively. Logistic regression models revealed that education was positively associated with ACP discussion in Taichung and Honolulu. Social media use was positively associated with ACP discussions in Wuhan and Honolulu, and it attenuated the association between education and ACP discussion in Honolulu. The present study contributes to previous studies by comparing the associations between education, social media use, and ACP discussion in different settings within the same ethnicity. Policy and practice implications were also discussed.

Public awareness of advance care planning and hospice palliative care: a nationwide cross-sectional study in Korea

CONTEXT

Advance care planning (ACP) and hospice palliative care (HPC) have potential benefits for individuals and health systems. Public awareness of them might increase their acceptance.

OBJECTIVES

To examine public awareness of ACP and HPC and related factors including individuals' experience of health care among Korean population.

METHODS

A cross-sectional study based on a nationally representative sample was conducted. Data from participants aged 15 years or older were examined. Socio-demographic characteristics, health-related factors, health care experience in the past year, and awareness of ACP and HPC were analyzed. Subgroup analysis was conducted to determine associations between specific experiences during outpatient visit and awareness of ACP and HPC.

RESULTS

Of a total of 13,546 subjects, 39.3% and 35.7% reported awareness of ACP and HPC, respectively. About half (48.6%) of participants reported that they were completely unaware of ACP or HPC. Recent outpatient visit was positively associated with HPC awareness. Participants were more likely to recognize ACP or HPC if they had experience in hospitalization and health checkup over the past year and had trust in the medical system. Conversely, participants who had inadequate health care access due to cost burden showed low awareness of ACP and HPC.

CONCLUSION

There was a lack of public awareness of ACP and HPC. There were significant differences depending on various factors, especially individual health care experiences. Appropriate interventions are needed to facilitate discussion of ACP and HPC, thereby increasing public awareness.

Comparative study of the effect of National Health Insurance Scheme on use of delivery and antenatal care services between rural and urban women in Ghana

BACKGROUND

Despite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana. The objective of this study was to examine the rural-urban differences in the effects of NHIS enrolment on delivery care utilisation (place of delivery and assistance at delivery) and antenatal care services among Ghanaian women.

METHODS

A nationally representative sample of 4169 women from the 2014 Ghana Demographic and Health Survey was used. Out of this sample, 2880 women are enrolled in the NHIS with 1229 and 1651 being urban and rural dwellers, respectively. Multivariate logistic and negative binomial models were fitted as the main estimation techniques. In addition, the Propensity Score Matching technique was used to verify rural-urban differences.

RESULTS

At the national level, enrolment in NHIS was observed to increase delivery care utilisation and the number of ANC visits in Ghana. However, rural-urban differences in effects were pronounced: whereas rural women who are enrolled in the NHIS were more likely to utilise delivery care [delivery in a health facility (OR = 1.870; CI = 1.533-2.281) and assisted delivery by a medical professional (OR = 1.994; CI = 1.631-2.438)], and have a higher number of ANC visits (IRR = 1.158; CI = 1.110-1.208) than their counterparts who are not enrolled, urban women who are enrolled in the NHIS on the other hand, recorded statistically insignificant results compared to their counterparts not enrolled. The PSM results corroborated the rural-urban differences in effects.

CONCLUSION

The rural-urban differences in delivery and antenatal care utilisation are in favour of rural women enrolled in the NHIS. Given that poverty is endemic in rural Ghana, this positions the NHIS as a potential social equaliser in maternal health care utilisation especially in the context of developing countries by increasing access to delivery care services and the number of ANC visits.

Willingness of patients with chronic disease in rural China to contract with family doctors: implication for targeting characteristics

BACKGROUND

Rural residents with chronic conditions have a stronger need for health services, which should make using family doctor contract services a priority. This study aimed to evaluate the rate of willingness among rural residents with chronic conditions to contract with family doctors and examine its determinants.

METHODS

A cross-sectional study was conducted from May, 2018 to June, 2018 in Shandong Province in China. A total of 769 rural unsigned residents with chronic conditions were included in the analysis. Using the Andersen model as the theoretical framework, logistic regression models were chosen to analyse the factors associated with willingness to contract with family doctors.

RESULTS

This study found that the rate of willingness to contract with family doctors among chronic patients in rural Shandong was 46.7%. A higher willingness was observed in those living a further distance from the village clinic (more than 600 m: OR = 1.85, 95%CI =1.17-2.93), having received publicity for family doctor contract services (OR = 1.71, 95% CI = 1.06-2.76), reporting need for utilizing a chronic disease management program (OR = 3.36, 95% CI = 2.20-5.23), and reporting need for higher medical insurance reimbursement (OR = 1.91, 95% CI = 1.28-2.83).

CONCLUSIONS

The prevalence of contract willingness was relatively low among unsigned rural residents with chronic conditions in rural Shandong, China. The need factors were powerful factors affecting their willingness to contract with family doctors. The government should therefore strengthen targeted publicity and education to rural residents with chronic conditions and provide targeted healthcare services, such as chronic disease management programs and medical services with higher reimbursement rates, to promote their willingness to contract with family doctors.

Protocol for a scoping review to evaluate the extent of utilisation of healthcare services by asthma patients in sub-Saharan African countries

INTRODUCTION

Health systems in sub-Saharan African (SSA) countries are fragile and centralised. Consequently, majority of people have restricted access to healthcare services. Given the rise in the prevalence and burden of asthma in SSA, it is imperative to scrutinise the utilisation of healthcare services by people with asthma. We aim to understand, through this review, the extent of utilisation of healthcare services by asthma patients in SSA countries.

METHODS AND ANALYSIS

Arksey and O'Malley's scoping review methodology framework will be used to guide the conduct of this scoping review. We will conduct a search of the literature on the electronic databases: Medline, (using PubMed interface), EMBASE, EBSCOHOST, Web of Science and Google Scholar, grey literature sources and the reference lists of key studies to identify studies appropriate for inclusion. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Registration of the proposed scoping review on the PROSPERO has indicated that no similar work has been or is being done elsewhere. We will review studies published on the subject from January 2009 to May 2020 in SSA.

ETHICS AND DISSEMINATION

The proposed scoping review will contribute towards the knowledge base on utilisation of healthcare services particularly for people with asthma. This will provide a better understanding of the extent of utilisation of healthcare services by asthma patients and ultimately contribute to improvement of quality of care for people suffering from asthma. The results from the review will enlighten and guide healthcare practitioners and researchers on developing appropriate and feasible interventions to increase the utilisation of healthcare services by asthma patients in resource-constrained settings in SSA countries. Results of this scoping review will be disseminated through a peer-reviewed publication, conference presentations and a 1-day stakeholder meeting.

PROSPERO REGISTRATION NUMBER

CRD42020154127.

Increasing Advance Care Planning Conversations Among Korean Americans Through a Faith Community Nurse Intervention

ABSTRACT

Minority populations have lower rates of advance care planning (ACP) than the general population. Faith community nurses (FCNs) can facilitate ACP training to improve end-of-life care outcomes for patients and caregivers. A nurse-led ACP training delivered to a primarily Korean American faith community increased the number of families who discussed end-of-life care values and wishes. Considerations for ACP outreach to Korean Americans and implications for FCNs are discussed.

Palliative Care for the Asian American Adult Population: A Scoping Review

BACKGROUND

The Asian American (AA) population is rapidly becoming one of the largest racial/ethnic groups in the United States. Despite this growth and advances in palliative care (PC) programs in the United States, the scope and nature of the literature regarding PC for AAs remains unclear. This review provides an overview of existing research on PC for AAs, identifies gaps in the research with recommendations for future research and delineates practice implications.

METHODS

A scoping review of studies published in English was conducted. Electronic Databases (PubMed, Embase, CINAHL, and PsycINFO databases) were searched up to December 2019. No starting date limit was set. Arksey and O'Malley's methodological framework was followed for scoping reviews.

RESULTS

Of 2390 publications initially identified, 42 studies met our inclusion criteria for this review. Southeast AA subgroups remain understudied compared to East and South AAs. Most studies were descriptive; a few (n = 3) evaluated effectiveness of PC interventions for AAs. Research synthesized in this review addresses the following topics and includes considerations in PC related to care recipients and their relatives: treatment choice discussions (73%), coordination of care with health care providers (26%), symptom management (14%), and emotional support (10%). This review identified various factors around PC for AAs, specifically the influence of cultural aspects, including levels of acculturation, traditional norms and values, and religious beliefs.

CONCLUSION

A culturally inclusive approach is vital to providing appropriate and accessible PC for AAs. Further research is needed concerning core PC components and effective interventions across diverse AA subgroups.

Cultural differences in the intended use of long-term care services in the United States: The role of family ties

OBJECTIVES

In the light of an increasingly diverse older population in the United States, there is an ongoing discussion how cultural factors contribute to individual long-term care (LTC) needs and service use. This study empirically assesses whether the level of acculturation and cultural differences in the importance of the family shape foreign-born immigrants' intention to use certain LTC services.

METHODS

We correlated immigrants' intention to use certain LTC services to the cultural strength of family ties that prevails in their region of origin. We used data from the National Health Interview Survey and the World Values Survey/European Values Study for analysis. Multinomial logit models were estimated and predisposing, enabling, and need factors were controlled for. Estimations were weighted to account for the sampling structure and sensitivity analyses were conducted.

RESULTS

Immigrants from cultures with stronger family ties are significantly more likely to intend the use of LTC options that include the family. Furthermore, immigrants are less likely to intend the use of exclusively family care when having lived in the United States for a longer time.

DISCUSSION

We conclude that cultural differences in family ties shape immigrants' intention to use certain LTC services. If policy makers aim at increasing the provision of specific LTC services or support to family caregivers, there should be a careful evaluation of demand-side factors in an increasingly culturally diverse society.

Investigation of the awareness of and demand for hospice care and attitudes towards life-sustaining treatment at the end of life among community residents in Hangzhou

BACKGROUND

To understand the status of residents' awareness of and demand for hospice care services in Hangzhou and to provide a reference for promoting the formulation of hospice care-related policies in China.

METHODS

A small cross-sectional survey of 519 adults aged over 40 years old living in the rural-urban fringe and urban area of Xihu District, Hangzhou City, was conducted using convenience sampling and a self-designed questionnaire. The measures assessed awareness of hospice care (13-item scale), attitudes towards life support therapy (3-item scale), and demand for hospice care services (9-item scale).

RESULTS

The rate of awareness of hospice care among community residents was 50.30%. A total of 51.0% of residents wanted only comfortable life-sustaining treatment at the end of their lives. The acceptance of hospice care was positively correlated with the degree of understanding (x² = 18.382, P = 0.001), and residents in the urban area were more likely to prefer hospice care than residents in the urban-rural fringe (x² = 7.186, P = 0.028). Elderly residents showed a stronger tendency to prefer comfortable life support therapy (x² = 12.988, P < 0.001). A total of 83.04% of the residents accepted the current necessity for hospice care to be provided in medical institutions. The preferred locations were professional hospice care institutions or general hospitals. A total of 93.64% of the residents agreed that the number of beds in hospice care wards should not exceed 2. In addition, the residents could afford part of the out-of-pocket expenses for hospice care services, with the ability to pay under 200 yuan per day, and the improvement of facilities was expected.

CONCLUSIONS

To improve public awareness and acceptance of hospice care and promote healthy development in China, it is necessary to promote hospice care education for everyone.

Disaggregating the Asian “Other”: Heterogeneity and Methodological Issues in Research on Asian Americans with Disabilities

Asian Americans comprise the fastest growing racial or ethnic group in the US. Between 2000 and 2019, their numbers almost doubled, from 11.9 million to 22.2 million. The numbers of people with disabilities within this demographically important population, which are also growing, puts stress on the service delivery sector. This situation indicates a pressing need for research on lived experiences of disabled Asian Americans. A review of the extant literature shows that Asian Americans are underrepresented in the research on disability and/or mental health. This lack of hard data is compounded by the tendency to treat Asian ethnicities as monolithic. The US Census Bureau recognizes more than 20 distinct Asian nationalities, ranging from South Asian Pakistani Americans to Southeast Asian Americans. Aggregating all Asian Americans together in surveys and studies impedes a sophisticated understanding of their unique needs and strengths. From a policy or systems perspective, inadequate data representation in the research literature, including outdated conclusions, is an implicit form of disenfranchisement. This conceptual article examines issues and implications around the lack of systematic attention to diversity within the Asian American population in disability research.

Sociocultural Factors Associated with Awareness of Palliative Care and Advanced Care Planning among Asian Populations

Objective

Underutilization of palliative care (PC) among racial/ethnic minorities remains consistent despite projected demand. The purpose of this study was to examine knowledge of palliative care and advanced care planning (ACP) and potential variations among subgroups of Asian Americans.

Design

A survey was conducted to collect information about awareness, knowledge, and perspective of PC and ACP in the southwestern region of the United States, from October 2018 to February 2019. A total of 212 surveys were collected from the general public at such places as health fairs, New Year celebration events, church, and community centers; 154 surveys were included in the descriptive and multivariate data analysis.

Results

About 46.1% and 40.3% participants reported having heard of palliative care and advanced care planning, respectively. The average score of the Knowledge of Care Options Instrument (KOCO) was 6.03 out of 11 and the average score of the Palliative Care Knowledge Scale (PaCKS) was 4.38 out of 13. Among those who have heard of PC, both Chinese (odds ratio (OR) .19 [CI, .05, .73]) and Vietnamese (.22 [.06, .84]) were less likely to have heard of palliative care compared with Filipinos (1.00). Among those who have ever heard of advanced care planning, age (.60 [.43, .84]) was negatively and education level (1.91 [1.18, 3.08]) was positively associated with awareness about advanced care planning. The majority of survey participants preferred family members to serve as their power attorneys.

Conclusion

The low levels of palliative care and advanced care planning awareness and knowledge in the diverse Asian groups living in the United States raise concerns and shed light on the critical need for culturally appropriate education programs.

Factors Influencing Residents' Willingness to Contract With General Practitioners in Guangzhou, China, During the GP Policy Trial Phase: A Cross-Sectional Study Based on Andersen's Behavioral Model of Health Services Use

This study aimed to investigate the current contract rate and residents’ willingness to contract with general practitioner (GP) services in Guangzhou, China, during the policy trial phase, and also to explore the association of behavior contract and contract willingness with variables based on Andersen’s Behavioral Model of Health Services Use (ABM). In total, 160 residents from community health centers (CHCs) and 202 residents from hospitals were recruited in this study. The outcome variables were behavior contract and contract willingness. Based on the framework of ABM, independent variables were categorized as predisposing factors, enabling factors, need factors, and CHC service utilization experiences. Univariate and multivariate logistic regression analysis models were applied to explore the associated factors. Out of 362 participants, 14.4% had contracted with GP services. For those who had not contracted with GP services, only 16.4% (51 out of 310) claimed they were willing to do so. The contract rate for community-based participants was significantly higher than that for hospital-based participants. Major reasons for not choosing to contract were perceiving no benefit from the service and concerns about the quality of CHCs. Community health center experiences and satisfaction were significantly associated with contracting among hospital-based participants. A need factor (diagnosed with hypertension or diabetes) and CHC service utilization experiences (have gotten services from the same doctor in CHCs) were significantly associated with contract willingness among CHC-based participants. Intervention to improve awareness of GP services may help to promote this service. Different intervention strategies should be used for varying resident populations.

Methods for overcoming barriers in palliative care for ethnic/racial minorities: a systematic review

OBJECTIVES

Ethnic/racial minority groups are less likely to discuss issues involving end-of-life treatment preferences and utilize palliative care or hospice services. Some barriers may be differences in language, religion, lower levels of health literacy, or less access to healthcare services and information. The purpose of this article is to conduct a systematic review on interventional studies that investigated methods to overcome the barriers faced by ethnic/racial minorities when accessing end-of-life services, including completing advanced directives, accepting palliative care, and enrolling in hospice.

METHODS

Literature searches using four standard scientific search engines were conducted to retrieve articles detailing original research in an interventional trial design. All studies were conducted in an outpatient setting, including primary care visits, home visits, and dialysis centers. Target populations were those identified from ethnic or racial minorities.

RESULTS

Nine articles were selected to be included in the final review. All were full-text English language articles, with target populations including African Americans, Hispanic or Latinos, and Asian or Pacific Islanders. Measured outcomes involved level of comfort in discussing and knowledge of palliative care services, desire for aggressive care at the end-of-life, completion of advance directives, and rate of enrollment in hospice.

SIGNIFICANCE OF RESULTS

Three main avenues of interventions included methods to enhance patient education, increase access to healthcare, or improve communication to establish better rapport with target population. Studies indicate that traditional delivery of healthcare services may be insufficient to recruit patients from ethnic/racial minorities, and outcomes can be improved by implementing tailored interventions to overcome barriers.

Does Acculturation Matter? End-of-Life Care Planning and Preference of Foreign-born Older Immigrants in the United States

Background and Objectives

Advance care planning (ACP) is a critical component of health care affecting the quality of later life. Responding to the increase in the older immigrant population in the United States, this empirical study explored the racial/ethnic gaps in ACP behaviors among older immigrants and examined the end-of-life (EOL) care planning and preferences of foreign-born immigrant older adults focusing on race/ethnicity, acculturation, health need factors, and enabling social factors (financial capability, public assistance, and informal supports) after controlling predisposing factors (sociodemographic characteristics).

Research Design and Methods

Using a subsample from the National Health and Aging Trends Study 2011 and 2012, hierarchical logistic regression models of the EOL plan and preferences were examined with 50 multiple imputation data sets (n = 232).

Results

Descriptive statistics reveal lower ACP engagement of immigrants from racial/ethnic minority groups. In logistic models, however, only Black immigrants were less likely than Whites to have EOL conversations. Among acculturation factors, age at immigration was only negatively associated with having a durable power of attorney for health, but not significantly associated with other ACP behaviors. Instead, health and social factors, primarily need in health and informal support (i.e., number of coresidents and receiving financial help from family members), were associated with different types of ACP components. Receiving public assistance (i.e., receiving Medicaid and SSI) were positively associated with EOL treatment preferences.

Discussion and Implications

Older foreign-born immigrants, in general, showed lower ACP engagement than the overall older population. Moreover, minority immigrants were lower on ACP engagement than both White immigrants. This study highlights the need for formal and informal assistance for enhancing EOL planning for older immigrants. Adding to the culturally competent approach, policy efforts should address social and health factors that accrued throughout individuals’ life spans and affect older immigrants’ EOL preparation and care.

The Intention to Discuss Advance Care Planning in the Context of Alzheimer's Disease Among Korean Americans

BACKGROUND AND OBJECTIVES

Advance care planning (ACP) is crucial for quality end-of-life care for patients with Alzheimer's disease. However, limited evidence is available about ACP among ethnic minorities, particularly in the context of Alzheimer's disease. The purpose of this study was to examine intention to discuss ACP for a family member with Alzheimer's disease among Korean Americans. Guided by the theory of planned behavior and prior research, we examined the relationships between acculturation, attitudes, subjective norms, perceived control, and intention to discuss ACP for a family member with Alzheimer's disease.

RESEARCH DESIGN AND METHODS

Path analyses were conducted on a cross-sectional convenience sample of 261 Korean Americans. Age, gender, education, and knowledge about Alzheimer's disease and ACP were included as covariates.

RESULTS

Our descriptive findings showed positive attitudes, strong subjective norms, and a high level of perceived control toward ACP discussion among the participants. The path analyses revealed that attitudes and subjective norms were positively related to intention for ACP discussion. Perceived control was not related to intention for ACP discussion. Among the covariates, greater knowledge about Alzheimer's disease was the only factor shown to be associated with the intention for ACP discussion.

DISCUSSION AND IMPLICATIONS

To promote ACP among this population, educational interventions designed to address positives attitudes and subjective norms toward ACP are suggested.

Understanding the predisposing, enabling, and reinforcing factors influencing the use of a mobile-based HIV management app: A real-world usability evaluation

OBJECTIVE

To conduct an in-depth analysis of users' experiences using an HIV self-management app.

MATERIALS AND METHODS

We conducted four follow-up focus groups at the end of a 3-month randomized feasibility trial. All focus group sessions were audio-recorded and transcribed. A thematic analysis was conducted to explore emerging themes. All of the themes were categorized into three factors of the PRECEDE component of the PRECEDE-PROCEED framework. For a finer granularity of analysis, the codes of each theme were broken into positive, negative, and neutral codes by study group.

RESULTS

36 participants, including 24 from the intervention group and 12 from the control group, participated in the focus group sessions. A total of 14 themes organized by the PRECEDE factors were identified from focus group transcripts. Five themes related to predisposing factors were: 1) ease of app use; 2) user-friendly functionality; 3) self-efficacy for symptom management; 4) design preference of illustrated strategies with videos; and 5) user-control (convenience vs. security). Four themes related to enabling factors were: 1) information needs of symptom management; 2) symptom-tracking; 3) fit in lifestyle/schedule/living conditions; and 4) additional languages (e.g., Spanish). Five themes related to reinforcing factors were: 1) communication with healthcare providers; 2) individual-tailored information visualization; 3) social networking; 4) individual-tailored information quality; and 5) improvement in quality of life.

DISCUSSION AND CONCLUSION

Usability evaluation in a real-world setting enabled us to measure users' actual experiences when interacting with the app during their everyday lives. Our work highlights the importance of using mobile technology for persons living with HIV, specifically those with low income/housing instability, and adds to the body of literature on the potential for implementation and dissemination of symptom self-management strategies through a mobile platform.

The impact of predisposing, enabling, and need factors in utilization of health services among rural residents in Guangxi, China

Background

Healthcare in China has significantly improved, meanwhile many  socio-economic risk factors and health conditions factors affect accessibility and utilization of health services in rural areas. Inequity of health service in China needs to  be estimated and reduced. Andersen behavioral model is useful to assess the association of health service utilization with predisposing, enabling, and need factors.

Methods

A survey was conducted among 4634 residents of 897 households in 2012. Logistic regression analysis was performed to explore the association of predisposing (age, gender, marital status, ethnicity and family size), enabling (education level, travel time to the nearest health facility, medical expense per capita, and health insurance coverage), and need factors (chronic disease) with the utilization of health services (i.e. physician visit and hospitalization).

Results

We observed a significant association between need factor (chronic diseases) and health service unitization, after adjusting for all predisposing and enabling factors (physician visits: odds ratio (OR) = 5.87, 95 % confidence interval (CI) = 4.71–7.32; hospitalization: OR = 4.04, 95 % CI = 2.90–5.61, respectively). In addition, age, gender, marital status, family size and education level were significant predictors of health service utilization. The travel time to the nearest health facility was associated with the utilization of physician visits, and expenditure on healthcare was a hindering factor of hospitalization.

Conclusions

The predisposing and enabling factors had a minor impact on health service utilization, while the need factor was a dominant predictor of health service utilization among rural residents in China.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1825-4) contains supplementary material, which is available to authorized users.

Older Adults of Underrepresented Populations and Their End-of-Life Preferences: An Integrative Review

This integrative review was conducted to examine the evidence for understanding diversity in end-of-life preferences among older adults of underrepresented groups. Findings from 21 studies were critically examined, grouped, and compared across studies, populations, and settings. Five major themes emerged: advance directives, hospice and palliative care, communication, knowledge and information, and home and family. Despite multidisciplinary attention, content and methodological limitations narrowed understanding of what matters most to these groups when making decisions at end of life. Rigorous longitudinal studies with more ethnically diverse samples are needed to detect modifiable factors related to disparities at the end of life.

Advance care planning in South Korea: Social work perspective

As ethical issues arise concerning the continuation of futile medical treatment for dying patients in Korean society, advance directive planning initiatives have been put into place to guide practice. This article describes the awareness and attitudes of social workers in Korea regarding advance care planning and related factors. A total of 246 gerontological/geriatric social workers completed a mailed or in-person survey regarding awareness and attitudes toward advance care planning. Seventy-three percent (n = 180) of the participants reported no knowledge of advance directives. Social workers who emphasized self-determination as a professional value, professed a preference for hospice care, and who were comfortable discussing death were more likely to have a positive attitudes toward advance care planning. This study reinforces the need for the infusion of advance care planning and end-of-life training in social work education in Korea.

A knowledge synthesis of culturally- and spiritually-sensitive end-of-life care: findings from a scoping review

BACKGROUND

Multiple factors influence the end-of-life (EoL) care and experience of poor quality services by culturally- and spiritually-diverse groups. Access to EoL services e.g. health and social supports at home or in hospices is difficult for ethnic minorities compared to white European groups. A tool is required to empower patients and families to access culturally-safe care. This review was undertaken by the Canadian Virtual Hospice as a foundation for this tool.

METHODS

To explore attitudes, behaviours and patterns to utilization of EoL care by culturally and spiritually diverse groups and identify gaps in EoL care practice and delivery methods, a scoping review and thematic analysis of article content was conducted. Fourteen electronic databases and websites were searched between June-August 2014 to identify English-language peer-reviewed publications and grey literature (including reports and other online resources) published between 2004-2014.

RESULTS

The search identified barriers and enablers at the systems, community and personal/family levels. Primary barriers include: cultural differences between healthcare providers; persons approaching EoL and family members; under-utilization of culturally-sensitive models designed to improve EoL care; language barriers; lack of awareness of cultural and religious diversity issues; exclusion of families in the decision-making process; personal racial and religious discrimination; and lack of culturally-tailored EoL information to facilitate decision-making.

CONCLUSIONS

This review highlights that most research has focused on decision-making. There were fewer studies exploring different cultural and spiritual experiences at the EoL and interventions to improve EoL care. Interventions evaluated were largely educational in nature rather than service oriented.

Emotional Confidants in Ethnic Communities: Social Network Analysis of Korean American Older Adults

OBJECTIVE

Ethnic communities often serve as the primary source of emotional support for older immigrants. This study aims to identify individuals who are more likely to be nominated as emotional confidants by age peers in the ethnic community and to examine factors contributing to the likelihood of being a more frequently endorsed confidant.

METHOD

Data were drawn from a survey with 675 older Korean Americans. Using the name-generator approach in Social Network Analysis (SNA), participants were asked to list the names of three emotional confidants among age peers in the community.

RESULTS

A higher level of popularity (i.e., in-degree centrality) was predicted by male gender, advanced education, lower functional disability, fewer symptoms of depression, and higher levels of participation in social activities.

DISCUSSION

Our findings suggest the value of SNA as a means of identifying the key emotional confidants in the community and utilizing them in community-based interventions.

Factors Affecting Willingness to Use Hospice in Racially/Ethnically Diverse Older Men and Women

Racial/ethnic minorities tend to underutilize hospice services. Guided by Andersen behavioral health model, the purpose of this study was to explore the predictors of the willingness to use hospice services in racially/ethnically diverse older men and women. Data were drawn from the Survey of Older Floridians: 504 non-Hispanic whites, 360 African Americans, 328 Cuban Americans, and 241 non-Cuban Hispanics. In each group, logistic regression models of the willingness to use hospice were estimated. A greater likelihood of willingness was observed among younger non-Hispanic whites and among African Americans with fewer functional disabilities. In non-Cuban Hispanics, English proficiency increased the willingness by 3.1 times. Findings of the study identified group-specific factors contributing to the willingness to use hospice services and hold implications for tailored intervention programs.

Sources of Response Bias in Older Ethnic Minorities: A Case of Korean American Elderly

The present study was undertaken to investigate potential sources of response bias in empirical research involving older ethnic minorities and to identify prudent strategies to reduce those biases, using Korean American elderly (KAE) as an example. Data were obtained from three independent studies of KAE (N = 1,297; age ≥60) in three states (Florida, New York, and Maryland) from 2000 to 2008. Two common measures, Pearlin's Mastery Scale and the CES-D scale, were selected for a series of psychometric tests based on classical measurement theory. Survey items were analyzed in depth, using psychometric properties generated from both exploratory factor analysis and confirmatory factor analysis as well as correlational analysis. Two types of potential sources of bias were identified as the most significant contributors to increases in error variances for these psychological instruments. Error variances were most prominent when (1) items were not presented in a manner that was culturally or contextually congruent with respect to the target population and/or (2) the response anchors for items were mixed (e.g., positive vs. negative). The systemic patterns and magnitudes of the biases were also cross-validated for the three studies. The results demonstrate sources and impacts of measurement biases in studies of older ethnic minorities. The identified response biases highlight the need for re-evaluation of current measurement practices, which are based on traditional recommendations that response anchors should be mixed or that the original wording of instruments should be rigidly followed. Specifically, systematic guidelines for accommodating cultural and contextual backgrounds into instrument design are warranted.

Risk Factors for Social Isolation in Older Korean Americans

OBJECTIVE

Given the importance of social ties and connectedness in the lives of older ethnic immigrants, the present study examined the prevalence of social isolation and its risk factors in older Korean Americans.

METHOD

Using survey data from 1,301 participants (Mage = 70.5, SD = 7.24), risk groups for marginal social ties with family and friends were identified and predictors of each type of social isolation explored.

RESULTS

Male gender and poorer rating of health were identified as common risk factors for marginal ties to both family and friends. Findings also present specific risk factors for each type of social isolation. For example, an increased risk of having marginal ties with friends was observed among individuals with perceived financial strain, greater functional impairment, and a shorter stay in the United States.

DISCUSSION

The common and specific risk factors should be incorporated in programs to reduce social isolation in older immigrant populations.

Just ask: hospice familiarity in Asian and Hispanic adults

CONTEXT

Previous research documents the under-utilization of hospice services by minority ethnic groups, but less data exist for Asian and Hispanic Americans. It is unclear whether these low utilization rates are a result of attitudinal or information barriers, or both.

OBJECTIVES

To examine self-reported familiarity and attitudes toward hospice among Asian and Hispanic groups in ethnically diverse Queens County, NY.

METHODS

We surveyed diverse adults during health fairs, at senior centers, and church programs directed at ethnic populations. Respondents completed surveys in their preferred language: Spanish, Chinese (Mandarin), and Korean. Analysis of variance was used to compare continuous variables among language groups; Fisher's exact test compared categorical variables.

RESULTS

A total of 604 community adults were surveyed: 99 Chinese, 349 Korean, 156 Spanish. Respondents were mostly female, average age 53 years. Familiarity with hospice varied significantly among the groups (P < 0.001) and was lower in the Hispanic (16%) and higher in the Chinese (45%) and Korean (56%) groups. Personal experiences with hospice were low (8-16%) in all groups. A majority (75-94%) responded they would share hospice information with loved ones, but the Hispanic group was significantly less likely to do so compared with Chinese and Korean Americans. Between 74 and 95% reported willingness to receive future information about hospice, but the Korean group was significantly less likely to want information.

CONCLUSION

When surveyed in their preferred language, Asian and Hispanic adults reported variable levels of familiarity with hospice services. Most responded positively to receiving future information and would tell friends and family members about hospice.

Awareness and completion of advance directives in older Korean-American adults

There has been growing concern about racial and ethnic disparities in completion rates of advance directives (ADs) in community-dwelling older populations. Although differences in AD completion rates between non-Hispanic whites and African Americans have been reported, not much is known about the awareness and completion of ADs in other groups of ethnic minorities. Using a sample of community-dwelling Korean-American older adults (n=675) as a target, factors associated with their awareness and completion of ADs were explored. Guided by Andersen's behavioral health model, predisposing (age, sex, marital status, education), need (chronic conditions, functional disability), and enabling (health insurance, acculturation) variables were included in the separate logistic regression models of AD awareness and AD completion. In both models, acculturation was found to be a significant predictor; those who were more acculturated were more likely to be aware of ADs and to have completed ADs. This study contributes to the knowledge about the role of acculturation in explaining AD awareness and completion in Korean-American older adults and provides recommendations for possible AD educational interventions for this older adult minority population.

The Impact of Acculturation on Depressive Symptoms: A Comparison of Older Korean Americans in Two Areas

This study examined how the impact of acculturation on depressive symptoms varied between two samples of older Korean Americans. One sample was from west central Florida (low Korean density area; n = 672), and the other from the New York City metropolitan area (high Korean density area; n = 420). The average level of acculturation was lower among older Korean Americans in New York, compared to those living in Florida. In the hierarchical regression models with the New York sample, acculturation was initially significant in predicting depressive symptoms; however, its impact was gradually attenuated and eventually became nonsignificant with the sequential entry of control variables. On the other hand, in the Florida sample, the impact of acculturation on depressive symptoms remained significant throughout the models. The results suggest that the level and importance of acculturation may differ by geographic locations and invite further contextual research in immigrant populations.

Provider-based research networks demonstrate greater hospice use for minority patients with lung cancer

PURPOSE

The Community Clinical Oncology Program (CCOP) and Minority-Based Community Clinical Oncology Program (MBCCOP) are provider-based research networks (PBRN) that improve minority enrollment in cancer-focused clinical trials. We hypothesized that affiliation with a PBRN may also mitigate racial differences in hospice enrollment for patients with lung cancer.

METHODS

We used the SEER-Medicare data, linked to the National Cancer Institute's CCOP program data, to identify all patients (≥ age 65 years) with lung cancer, diagnosed from 2001 to 2007. We defined clinical treatment settings as CCOP, MBCCOP, academic, or community-affiliated and used multivariable logistic regression analysis to determine factors associated with hospice enrollment.

RESULTS

Forty-one thousand eight hundred eighty-five (55.1%) patients with lung cancer enrolled in hospice before death. Approximately 55% of CCOP, 57% of MBCCOP, 57% of academic, and 52% of community patients enrolled. Patients who were more likely to enroll were female (odds ratio [OR], 1.36; 95% CI, 1.31 to 1.40); ≥ age 79 years (OR, 1.11; 95%CI, 1.06 to 1.16); white; lived in more educated areas; had minimal comorbidities; and had distant disease. Asian and black patients in academic (41.1% and 50.4%, respectively) and community practices (35.2% and 43.4%, respectively) were less likely to enroll in hospice compared with white patients (academic, 58.8%; community, 53.1%). However, hospice enrollment was equivalent for black and white patients in MBCCOP (59.5% v 57.2%) and CCOP (52.2% v 56.3%) practices.

CONCLUSION

Minority patients with lung cancer receiving treatment in cancer-focused PBRN- affiliated practices have greater hospice enrollment than those treated in academic and community practices.

Racial and ethnic disparities in palliative care

Racial and ethnic disparities in health care access and quality are well documented for some minority groups. However, compared to other areas of health care, such as disease prevention, early detection, and curative care, research in disparities in palliative care is limited. Given the rapidly growing population of minority older adults, many of whom will face advanced serious illness, the availability of high-quality palliative care that meets the varied needs of older adults of all races and ethnicities is a priority. This paper reviews existing data on racial and ethnic disparities in use of and quality of palliative care and outlines priorities for future research.

An empirical typology of social networks and its association with physical and mental health: a study with older Korean immigrants

OBJECTIVES

In the context of social convoy theory, the purposes of the study were (a) to identify an empirical typology of the social networks evident in older Korean immigrants and (b) to examine its association with self-rated health and depressive symptoms.

METHOD

The sample consisted of 1,092 community-dwelling older Korean immigrants in Florida and New York. Latent class analyses were conducted to identify the optimal social network typology based on 8 indicators of interpersonal relationships and activities. Bivariate and multivariate analyses were conducted to examine how the identified social network typology was associated with self-rating of health and depressive symptoms.

RESULTS

Results from the latent class analysis identified 6 clusters as being most optimal, and they were named diverse, unmarried/diverse, married/coresidence, family focused, unmarried/restricted, and restricted. Memberships in the clusters of diverse and married/coresidence were significantly associated with more favorable ratings of health and lower levels of depressive symptoms.

DISCUSSION

Notably, no distinct network solely composed of friends was identified in the present sample of older immigrants; this may reflect the disruptions in social convoys caused by immigration. The findings of this study promote our understanding of the unique patterns of social connectedness in older immigrants.

Complementary and alternative medicine utilization in Texas hospices: prevalence, importance, and challenges

The purpose of this study was to describe the prevalence, importance, and challenges of complementary and alternative medicine (CAM) utilization in Texas hospices. Mail surveys were sent to 369 hospices in Texas, and 110 useful surveys were returned. Results showed that a majority (n = 62, 56.4%) of hospices offer CAM to their clients, with the most popularly offered CAMs being massage, music, and relaxation therapies. Despite the availability of CAM services in most hospices, and that the utilization of CAM has the potential to improve overall quality of life of patients, our results showed that a sizeable proportion of patients in these hospices are not utilizing the provided CAMs. Funding and personnel constraints were substantial obstacles to offering CAM.

What evidence is available on end-of-life (EOL) care and Latino elders? A literature review

BACKGROUND

Low-income and minority persons, such as Latinos, encounter substantial barriers in accessing effective end-of-life (EOL) care. This study intends to review current evidence on how to deliver EOL care to Latino elders.

METHODS

Literature search in PubMed and Ovid Web sites of articles indexed in Medline (1948-2011), Cochrane (2005-2011), Embase, and PsychInfo (1967-2011) databases. Articles were included if they contained (1) study participants' race/ethnicity, (2) adults or population older than 60 years, and (3) information related to EOL care.

RESULTS

A total of 64 abstracts were reviewed, and 38 articles met the inclusion criteria. After reviewing the quality of evidence, 4 themes were identified and summarized: EOL preferences, hospice, Latino culture, and caregiving.

CONCLUSION

Latino elders have traditional acculturation practices, face EOL decisions with family support, and, if educated, are receptive toward hospice and caregiver support.

Psychosocial, cultural, and spiritual health disparities in end-of-life and palliative care: where we are and where we need to go

Although health disparities are well documented, the extent to which they affect end-of-life care is unknown. Limited research funding leads to sparse and often contradictory palliative care literature, with few studies on causal mechanisms. This article explores the psychosocial, cultural, and spiritual health disparities existing in palliative and end-of-life care with the goal of identifying future research needs. This article reports efforts to determine knowledge gaps related to health disparities in psychosocial, cultural, and spiritual aspects of end-of-life care in which the authors draw upon recent literature from multiple databases. Although few data are available, studies show that minorities make little use of hospice, often because of lack of knowledge about hospice or palliative care, family-centered cultures, and preferences for more aggressive end-of-life care than hospice allows. The authors conclude that future research should include a search for theoretical and causal mechanisms; prospective longitudinal investigations; diverse patients, conditions, contexts, and settings; methodological diversity and rigor; and interdisciplinary, culturally sensitive interventions.

Diabetes and depressive symptoms among Korean American older adults: the mediating role of subjective health perceptions

PURPOSE

In recognition of the impact of chronic diseases on mental health and the lack of research on Asian American subgroups, the present study examined subjective perceptions of health as a potential mediator in the association between diabetes and depressive symptoms in Korean American older adults.

METHODS

Multivariate analysis with data from 672 Korean American older adults in Florida explored the mediation model of health perceptions.

RESULTS

The presence of diabetes was associated with negative perceptions of health and elevated symptoms of depression. The proposed mediation model was also supported: negative perceptions of health served as an intervening step between diabetes and depressive symptoms.

CONCLUSIONS

The intervening role of health perceptions yields implications for developing health promotion interventions targeting older individuals with diabetes. Results suggest that even in the presence of chronic health conditions, mental well-being of older adults can be maintained by having optimistic beliefs and positive attitudes towards their own health.

The mediating role of loneliness in the relation between social engagement and depressive symptoms among older Korean Americans: do men and women differ?

OBJECTIVES

This study conceptualized loneliness as a mediator in the relation between social engagement and depressive symptoms and explored gender differences in the mediation model. Various indices of social engagement were considered including living arrangement, social network, and activity participation.

METHOD

Using data from 674 community-dwelling Korean American older adults, we first examined the mediation effect of loneliness in the relation between each of 3 indices of social engagement (not living alone, social network, and activity participation) and depressive symptoms. Subsequently, gender differences in the mediation model were examined.

RESULTS

As hypothesized, loneliness was found to mediate the relation between each of the indices of social engagement and depressive symptoms in both men and women. We also observed gender differences in the strength of mediating effects; the effect of living alone was more likely to be mediated by loneliness among men, whereas women showed greater levels of mediation in the models with social network and activity participation.

DISCUSSION

Our findings suggest that loneliness may explain the mechanism by which deficits in social engagement exerts its effect on depressive symptoms and that gender differences should be considered in interventions targeting social engagement for mental health promotion.

Neighborhood Effects on Physical and Mental Health: A Study of Korean American Older Adults

This study explored how the physical and mental health of Korean American older adults were influenced by neighborhood characteristics (i.e., proportion of individuals living below the poverty level, proportion of individuals 65 years of age and older, and proportion of racial/ethnic minorities in the census block groups where each respondent lived). Health perceptions (i.e., the subjective appraisal of one's own health) and depressive symptoms were used as indicators of physical and mental health. Multilevel analyses were performed with 567 individuals (at Level 1) nested within 233 census block groups (at Level 2). After controlling for individual demographic and health characteristics, we found that neighborhood poverty predicted health perceptions. The results add to the growing literature on the influence of the social environment and suggest that neighborhood characteristics should be taken into consideration in developing community-based policies for racially/ethnically diverse populations.

Use of healthcare access models to inform the patient protection and affordable care act

Health policy findings on access to care provide more substantive information if linked to a theory that provides meaningful structure and standard definitions. Three theories of access are reviewed here because they have been used to inform health policy: Penchansky's Model, The Institute of Medicine (IOM) Model of Access Monitoring, and The Behavioral Model of Health Services Use. Penchansky's model is useful when subjective experiences with health care access are needed to inform policy makers. The IOM model is used for monitoring quality of health care services provided. The Behavioral Model identifies explanatory/predictive factors associated with utilization of services. Each model uniquely evaluates different health policies. Given the passage of the Patient Protection and Affordable Care Act (PPACA) of 2010, researchers and policy makers must agree on the model that best monitors and evaluates these new policy initiatives.

Willingness to Use Mental Health Services Among Older Residents in Assisted Living

Examining the importance of mental health care in assisted living (AL) settings, the present study examines older AL residents’ willingness to use mental health services and its predictors. Data based on face-to-face interviews with 150 older residents from 17 AL settings in Florida are used in the analyses ( Mage = 82.8, SD = 9.4). Multivariate logistic regression is used to estimate the likelihood of willingness to use mental health services in relation to predisposing (demographics and physical health), mental health needs (depressive symptoms), and enabling variables (social network, instrumental support, emotional support, informational support, satisfaction with support, and previous use of mental health services). Willingness to use mental health services is predicted by younger age, unmarried status, lower levels of emotional support, and higher levels of informational support. The relationship of informational support to higher willingness to use mental health services suggests that AL residents could benefit from educational interventions on late life depression.

Not saying I am happy does not mean I am not: cultural influences on responses to positive affect items in the CES-D

OBJECTIVES

Given the emphasis on modesty and self-effacement in Asian societies, the present study explored differential item responses for 2 positive affect items (5 = Hopeful and 8 = Happy) on a short form of the Center for Epidemiologic Studies-Depression scale. The samples consisted of elderly non-Hispanic Whites (n = 450), Korean Americans (n = 519), and Koreans (n = 2,030).

METHOD

Multiple Indicator Multiple Cause models were estimated to identify the impact of group membership on responses to the positive affect items while controlling for the latent trait of depressive symptoms.

RESULTS

The data revealed that Koreans and Korean Americans were less likely than non-Hispanic Whites to endorse the positive affect items. Compared with Korean Americans who were more acculturated to mainstream American culture, those who were less acculturated were less likely to endorse the positive affect items.

DISCUSSION

Our findings support the notion that the way in which people endorse depressive symptoms is substantially influenced by cultural orientation. These findings call into question the common use of simple mean comparisons and a universal cutoff point across diverse cultural groups.

Why don't patients enroll in hospice? Can we do anything about it?

BACKGROUND

United States hospice organizations aim to provide quality, patient-centered end-of-life care to patients in the last 6 months of life, yet some of these organizations observe that some hospice-eligible patients who are referred to hospice do not initially enroll.

PRIMARY OBJECTIVE

To identify reasons that eligible patients do not enroll in hospice (phase 1).

SECONDARY OBJECTIVE

To identify strategies used by hospice providers to address these reasons (phase 2).

DESIGN

Semi-structured interviews analyzed using content analysis.

PARTICIPANTS

In phase 1, we interviewed 30 patients and/or family members of patients who had a hospice admissions visit, but who did not enroll. In phase 2, we interviewed 19 hospice staff and national experts.

APPROACH

In phase 1, we asked participants to describe the patient's illness, the hospice referral, and why they had not enrolled. We performed a content analysis to characterize their reasons for not enrolling in hospice. In phase 2, we enrolled hospice admissions staff and hospice experts. We asked them to describe how they would respond to each reason (from phase 1) during an admissions visit with a potential new hospice patient. We identified key phrases, and summarized their recommendations.

RESULTS

Reasons that patients hadn't enrolled fell into three broad categories: patient/family perceptions (e.g., "not ready"), hospice specific issues (e.g., variable definitions of hospice-eligible patients), and systems issues (e.g., concerns about continuity of care). Hospice staff/experts had encountered each reason, and offered strategies at the individual and organizational level for responding.

CONCLUSIONS

In hopes of increasing hospice enrollment among hospice-eligible patients, non-hospice and hospice clinicians may want to adopt some of the strategies used by hospice staff/experts for talking about hospice with patients/families and may want to familiarize themselves with the differences between hospice organizations in their area. Hospices may want to reconsider their admission policies and procedures in light of patients' and families' perceptions and concerns.

Knowledge of Depression Among Korean American Older Adults

The present study explored knowledge about depression and the factors that predict that knowledge in a sample of Korean American older adults (N = 675). Compared with other published results, knowledge of depression in the present sample was generally low. The participants provided on average only 42.6% correct answers on the 12-item Depression in Late Life Quiz, and for 9 items, more than 50% of the participants provided incorrect answers. In a multivariate linear regression, acculturation (β = .12, p < .01) and depressive symptoms (β = -.09, p < .05) were significant predictors of knowledge. Individuals with lower levels of acculturation had less knowledge of depression. An interesting finding was that those with higher levels of depressive symptoms exhibited poorer knowledge of depression. The study findings emphasized the need for educational interventions to be provided in order to improve the mental health literacy of Korean American older adults.