Written by Nicholas Faddis, Graduate Assistant with the Bronstein Center for Healthy Aging and Wellness
Dr. Junghee Han, MSW, PhD, USI Assistant Professor in Social Work, is the first recipient of the Bronstein Faculty Research and/or Innovation Award. She conducted an exploratory mixed-method study to identify potential factors affecting advance care planning and end-of-life care decisions among older Korean Americans in the Tri-State area, including Indiana, Tennessee and Missouri.
Please read the following article by Dr. Junghee Han, MSW, PhD:
Nine Korean immigrant older adults in the designated area were recruited through a two-stage sampling approach, which combined snowball sampling and convenience sampling. Both quantitative and qualitative data were gathered through a one-hour, in-depth, face-to-face interview. The interview was conducted in Korean, as per the participants' preference. Four of the participants were male. The mean age of study participants was 66.5 years, with a standard deviation of 4.12. They had spent an average of 34.2 years residing in the United States (SD=12.6 years, Range=13-51 years). An interesting finding was that despite living in the United States for an average of over 30 years, all of them continued to self-identify as Korean rather than embracing the identity of Korean Americans. Additionally, they predominantly spoke the Korean language within their households. Except for one respondent, all of them reported their health status as "very good" or "excellent" when asked to rate their physical health on a five-point scale ranging from "excellent" to "poor." All participants rated their mental health status as "good" or better.
Regarding advance directives, none of the participants had completed advance directives or received education about them. However, their knowledge of advance directives and life-sustaining treatments, as measured by a validated tool developed by Korean scholars with 10 items utilizing "yes," "no," or "not sure" responses (Incorrect or "not sure" responses were scored as 0, while correct answers received a score of 1), yielded overall high scores (M=6.2 points, SD=0.97 points) (Kim et al., 2013).
Attitudes toward advance directives (ADs) were assessed using a 16-item tool originally developed by Nolan and Bruder (1997) and translated into Korean by Lee and Park in 2014. The tool covered four domains: treatment choice opportunities (four items), family impact (eight items), treatment impact (three items), and illness perception (one item). Participants used a four-point Likert scale, with higher scores indicating more positive attitudes. In this study, total scores ranged from 35 to 56, with a mean of 46.5 and a standard deviation of 7.13, indicating a moderately positive attitude towards advance directives.
Despite high knowledge scores and moderately favorable attitudes among the participants, there was no link to advance directive completion, as eight participants had no intention to complete them in the near future. The findings suggested that factors other than knowledge and attitudes toward advance directives played a role in determining their completion. During the qualitative interviews, participants identified significant factors that prompted them to consider completing advance directives. These included their advancing age, medical condition, treatment options, family well-being and financial situation. This qualitative finding aligns with the quantitative result that all participants strongly agreed with the item, "I am not sick enough to create advance directives," on the attitudes toward advance directives scale.
Furthermore, none of the cultural factors, including acculturation and filial piety, was associated with completing advance directives. This study finding was supported by the qualitative interviews, where none of the study participants mentioned filial piety as a factor in their decision regarding the completion of advance directives.
This pilot study has significant implications for enhancing the well-being of racial/ethnic minority older adults, especially those residing in rural areas, who have often been overlooked. The study findings offer valuable insights into the timing and approach needed for discussing end-of-life care and decisions when working with Korean immigrant older adults in rural areas. Following the completion of this study, there are plans to replicate it with Korean immigrant older adults residing in New York City. Identifying factors associated with the completion of advance directives, which are consistently found across multiple similar studies, will aid in developing culturally competent strategies to enhance the quality of end-of-life care for racial/ethnic minorities in the United States.
