1. Southeast Asian Women’s Attitudes Toward Completing Advance Directives Lair Ky California State University, Long Beach May 2012

2. Introduction Southeast Asians are the fastest growing minority population in the United States, and are less likely to have completed advance directives or have end-of-life discussions with their family members (Newman, Davidhizar, & Fordham, 2006). Since family caregiving in the Asian culture is often associated with being female (Pinquart & Sorensen, 2005), the purpose of this study was to specifically explore the attitudes of Southeast Asian women toward completing advance directives and making end-of-life (EOL) care decisions for their family members. This study focused on two important research questions: What are the cultural considerations and views of Southeast Asians women in their knowledge and attitudes toward planning and completing an advance directive (AD)? How do Southeast Asian women perceive the impact of ADs on their families?

3. Cross-Cultural Relevance As the Southeast Asian population in Southern California continues to grow, and as people get older, the need for EOL care discussions will become more apparent. The low completion rate of AD among ethnic minorities (Kwak & Haley, 2005), point to a need for social workers to actively reach out to ethnic minority groups, from the stand point of this study, should focus on the Southeast Asian population to help them understand why ADs are important and highly encouraged among the U.S. health care system. With knowledge and cultural sensitivity social workers will be more equipped to better educate and assist this fast growing population of Southeast Asians on ADs and the importance of completing them, so that their EOL care wishes are known to their caregivers, families and their physicians.

4. Social Work Relevance Social workers are well-known in working with culturally diverse individuals and families (Congress, 2004). Social workers facilitate communication about ADs to individuals and families more frequently than physicians (Black, 2005). If social workers expect to effectively assist the range of population they work with in addressing EOL decision-making, they must adequately understand ADs and demonstrate positive attitudes regarding discussing and completing the documents (Baker, 2001).

5. Methods An exploratory quantitative design was used to examine the attitudes and perceived barriers in completing ADs and making EOL decisions among Southeast Asian women. The self- administered questionnaire consisted of two sections and a total of 26-items. Section one consisted of a 10-item demographic questionnaire, developed by the researcher. Section two consisted of a 16-item, four-point Likert scale examining attitudes toward ADs and EOL decisions, with four Advance Directive Attitudes Survey (ADAS) subscales (a) opportunity for treatment, (b) impact of AD on the family, (c) effect of AD on treatment, and (e) illness perception developed by Nolan and Bruder (1997).

6. Methods (continued) This study utilized three recruitment sources: (1) the Long Beach Friends Church, (2) the Long Beach New Life Church of Nazarene and (3) the snowball method, of people who may not necessarily attend the local churches, for the non-randomized convenience sampling of 70 Southeast Asian women. The criteria for participation in the study include: females who were Southeast Asian by heritage, were fluent in English, were between the ages of 30 – 60, and who made health care decisions for their family members. Data were analyzed using the Statistical Package for Social Sciences (SPSS) program. Descriptive and inferential tests including correlations, t-tests and one-way ANOVA procedures were conducted to compare the respondents’ knowledge and attitude scales to each of the demographic items.

7. Results Demographic Characteristics of Respondents (N = 70) ______________________________________________________________________________________________________________________________ Variable N% ______________________________________________________________________________________________________________________________ Ethnicity Laotian2231.4 Cambodian18 25.7 Filipino1622.9 Vietnamese1420.0 Marital Status Married5274.3 Not Married1825.7 Education High School Graduate or Less2028.6 Some College1420.0 College Graduate2231.4 Graduate Degree1420.0 Religion Christian/Protestant3144.3 Buddhist2231.4 Catholic1622.9 Missing data 1 1.4 AD Knowledge No3042.9 Yes4057.1 EOL Discussion with Family No4767.1 Yes2332.9 Completed AD for Self No6592.9 Yes 5 7.1 Completed AD for Family No6288.6 Yes 811.4 ______________________________________________________________________________________________________________________________

8. Results (continued) Characteristics of the Subscales within the ADAS (N = 70) For research question one: What are the cultural considerations and views of Southeast Asians women in their knowledge and attitudes toward planning and completing an advance directive (AD)? The ADAS subscales on (a) opportunity for treatment choices, (c) effect of an AD on treatment and (d) illness perception were examined. Overall, the respondents in this study are generally knowledgeable about AD, and have a positive attitude towards AD, especially in the area of opportunity for treatment choices, and effect of AD on treatment. For research question two: How do Southeast Asian women perceive the impact of ADs on their families? The ADAS subscale (b) impact of ADs on the family was examined. Sixty-three (90%) of the respondents agreed that their family would want them to have and AD. Furthermore, 65 (92.8%) of the respondents indicated that having an AD would keep their family from disagreeing over their treatment if they were unable to speak for themselves. SubscalePossible RangeObserved Range MSDReliability (α) Opportunity for Treatment Choices 4-168-1613.402.11.86 Impact of ADs on Family 8-3218-3224.473.34.75 Effect of an AD on Treatment 3-126-129.891.56.80 Illness Perception 1-4 2.66.93n/a

9. Discussion Surprisingly, the results from this study indicated that respondents who were Vietnamese, of Catholic faith, who had a graduate degree, and who had completed an AD for themselves scored consistently higher across all the ADAS subscales; suggesting that the respondents had a positive attitude towards ADs. The promising findings in this study echoed those of Douglas and Brown (2002) suggesting that respondents who recognize the need for ADs, who are aware of the benefits of AD, and who believe that ADs affect care positively at the end of life may be more apt to complete AD documents. The next steps for future research would be to include a larger study sample of the Southeast Asian population, translate the survey into other languages, combine both quantitative and qualitative study methods, and develop focus groups to help enhance EOL discussions among these populations. Since religion and spirituality are important aspects in EOL decisions, future research needs to also incorporate aspects of religiosity and belief systems as these clearly impact the individuals’ attitudes about AD and their usefulness. It would also be beneficial for health care professionals to find creative and innovative ways to provide education and interventions among the Southeast Asian population to help them overcome the multitudes of barriers that can hinder them from completing an AD, and ultimately enhance their quality in end-of-life care.

10. References Baker, M. E. (2001). Knowledge and attitudes of health care social workers regarding advance directives. Social Work in Health Care, 32(2), 61 -74. doi:10.1300/J010 v32n02_04 Black, K. (2005). Advance directive communication practices: Social workers’ contributions to the interdisciplinary heath care team. Social Work in Health Care, 40(3), 39-55. Congress, E. P. (2004). Cultural and ethical issues in working with culturally diverse patients and their families: The use of the culturagram to promote cultural competent practice in health care settings. Social Work in Health Care, 39(3/4), 249-262. doi:10.1300/J010v39n03_03 Douglas, R., & Brown, H. (2002). Patients' attitudes toward advance directives. Journal of Nursing Scholarship, 34(1), 61-65. Kwak, J., & Haley, W. E. (2005). Current research findings on end-of-life decision making among racially or ethnically diverse groups. Gerontologist, 45(5), 634-641. Newman, J., Davidhizar, R. E., & Fordham, P. (2006). Multi-cultural and multi-ethnic considerations and advanced directives: Developing cultural competency. Journal of Cultural Diversity, 13(1), 3-9. Nolan, M. T., & Bruder, M. (1997). Patients’ attitudes towards advance directives and end of life treatment decisions. Nursing Outlook, 45(5), 204-208. Pinquart, M., & Sörensen, S. (2005). Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: A meta-analysis. Gerontologist, 45(1), 90-106.