Family-Centered Decision Making for East Asian Adults With Mental Illness

Journey to inpatient hospice care: A qualitative study on the decision-making process of Chinese family caregivers of persons with terminal cancer

OBJECTIVE

To understand family caregivers' decision-making process to place their family members with terminal cancer in inpatient hospice care, especially in the social-cultural contexts whereby the caregivers have a dominant say about the care of their seriously ill family members.

METHODS

A qualitative study with a phenomenological approach was undertaken to understand the lived experience of caregivers of persons with terminal cancer in the decision-making process. Semi-structured qualitative interviews were conducted with a purposive sample of 17 caregivers in Shanghai, China. Thematic analysis was used to analyze the data.

RESULTS

The caregivers underwent a winding and socioculturally mediated four-stage process. The stages are (i) trigger for alternatives: lost hope for a cure, (ii) meandering the see-saw process, (iii) the last straws: physical limitations and witnessing unbearable suffering, and (iv) the aftermath: acceptance versus lingering hope. Caregivers' attitudes towards death and their family members with advanced cancer expressed care wishes influence the state of the aftermath.

CONCLUSIONS

Chinese sociocultural values and beliefs about caregiving and death provide insightful explanations for the observed process.

PRACTICAL IMPLICATIONS

Training healthcare professionals in cultural competence, developing an effective hospice referral system, and delivering socioculturally acceptable death education are critical interventions to facilitate better decision-making experiences.

Family Involvement in Asian American Health Interventions: A Scoping Review and Conceptual Model

Family members play a crucial role in the health of Asian American communities, and their involvement in health interventions can be pivotal in optimizing impact and implementation. To explore how family members can be effectively involved in Asian American health interventions and develop a conceptual framework of methods of involvement at the stages of intervention development, process, and evaluation, this scoping review documented the role of Asian American family members in interventions (across any health objective). Of the 7175 studies identified through database and manual searches, we included 48 studies in the final analysis. Many studies focused on Chinese (54%) or Vietnamese (21%) populations, were conducted in California (44%), and involved spouses (35%) or parents/children (39%). We observed involvement across 3 stages: (1) intervention development (formative research, review process, material development), (2) intervention process (recruitment, receiving the intervention together, receiving a parallel intervention, enlisting support to achieve goals, voluntary intervention support, agent of family-wide change, and participation gatekeepers), and (3) intervention evaluation (received evaluation together, indirect impact evaluation, and feedback during intervention). Impact of family member involvement was both positive (as sources of encouragement, insight, accountability, comfort, and passion) and negative (sources of hindrance, backlash, stigma, obligation, and negative influence). Suggestions for future research interventions include (1) exploring family involvement in South Asian or young adult interventions, (2) diversifying types of family members involved (eg, extended family), and (3) diversifying methods of involvement (eg, family members as implementation agents).

Cultural influences on shared decision-making among Asian Americans: A systematic review and meta-synthesis of qualitative studies

OBJECTIVE

To summarize how Asian Americans negotiate involvement in shared decision-making (SDM) with their providers, the cultural influences on SDM, and perceived barriers and facilitators to SDM.

METHODS

This is a systematic review of qualitative studies. We searched six electronic databases and sources of gray literature until March 2021. Two reviewers independently screened studies, performed quality appraisal, and data extraction. Meta-synthesis was performed to summarize themes using a three-step approach.

RESULTS

Twenty studies with 675 participants were included. We abstracted 275 initial codes and grouped these into 19 subthemes and 4 major themes: (1) negotiating power and differing expectations in SDM; (2) cultural influences on SDM; (3) importance of social support in SDM; and (4) supportive factors for facilitating SDM.

CONCLUSIONS

Asian Americans have important perspectives, needs, and preferences regarding SDM that impacts how they engage with the provider on medical decisions and their perception of the quality of their care.

PRACTICE IMPLICATIONS

Asian American patients valued good communication and sufficient time with their provider, and that it is important for health professionals to understand patients' desired level of involvement in the SDM process and in the final decision, and who should be involved in SDM beyond the patient.

OTHER

This systematic review was registered on PROSPERO (CRD42021241665).

The influence of routine and leisure family activities on the ability of young Asian Americans to maintain a healthy lifestyle: findings from a nationwide survey

Family is uniquely influential in the health of young Asian Americans (AAs), yet little is known on the impact of specific shared family activities. This study explores different types and frequencies of AA young adult shared family activities on perceived familial influence on the ability to maintain a healthy lifestyle (diet, physical activity, sleep, social relationships, stress, and risky substances). A nationwide sample of 18-35-year-old AAs was surveyed in March 2021 on a list of 30 shared family activities with mothers, fathers, siblings, or extended family. Overall, 984 unique family relationships reported by 616 young AAs were analyzed. Confirmatory factor analysis synthesized a reliable two-factor (routine, leisure activities) 10-item Shared Activities with Family (SAF) scale. Mothers were most influential (mean 3.25, SD = 1.14), although shared activities among South Asians or with extended family were most associated with changes in perceived influence. Routine shared activities were more strongly associated with perceived influence on sleep, diet, and risky substances, while leisure shared activities were more associated with influence on developing healthy social relationships. Family-based, dyadic interventions for young AAs may incorporate shared activities (both routine and leisure) to promote healthy behaviors, although further research to explore mechanisms and directionality of influence is needed to inform action.

Gothenburg Empowerment Scale (GES): psychometric properties and measurement invariance in adults with congenital heart disease from Belgium, Norway and South Korea

Background

Patient empowerment is associated with improvements in different patient-reported and clinical outcomes. However, despite being widely researched, high quality and theoretically substantiated disease-generic measures of patient empowerment are lacking. The few good instruments that are available have not reported important psychometric properties, including measurement invariance. The aim of this study was to assess the psychometric properties of the 15-item Gothenburg Empowerment Scale (GES), with a particular focus on measurement invariance of the GES across individuals from three countries.

Methods

Adults with congenital heart disease from Belgium, Norway and South Korea completed the GES and other patient-reported outcomes as part of an international, cross-sectional, descriptive study called APPROACH-IS II. The scale’s content (missing data) and factorial validity (confirmatory factor analyses), measurement invariance (multi-group confirmatory factor analyses), responsiveness (floor and ceiling effects) and reliability (internal consistency) were assessed.

Results

Content validity, responsiveness and reliability were confirmed. Nonetheless, metric but not scalar measurement invariance was supported when including the three countries, possibly because the scale performed differently in the sample from South Korea. A second set of analyses supported partial scalar invariance for a sample that was limited to Norway and Belgium.

Conclusion

Our study offers preliminary evidence that GES is a valid and reliable measure of patient empowerment in adults with congenital heart disease. However, cross-country comparisons must be made with caution, given the scale did not perform equivalently across the three countries.

A Qualitative Exploration of End-of-Life Care Planning With Korean Americans: Awareness, Attitudes, Barriers, and Preferences

This study aimed to explore how Korean American older adults viewed and anticipated engaging in end-of-life (EOL) care planning. An exploratory qualitative research design was adopted for the study, and data were collected through 3 focus group interviews. A total of 30 Korean American older adults 65 years or older participated in the study. A total of 10 themes emerged and were organized into 5 categories: (1) awareness (varying experience in EOL care planning and insufficient understanding about advance directives), (2) attitudes (comfort with talking about EOL and favorable views toward EOL planning), (3) barriers (concerns about noncompliance and concerns about change of mind), (4) preference for natural dying (life-sustaining treatment as added pain and suffering and no meaning of life when relying on life-sustaining treatment), and (5) preference for EOL planning process (EOL planning initiated by physicians and involvement of close family members). This exploratory study provides crucial insights into awareness and concerns regarding EOL care planning among Korean American older adults, updating existing evidence about their EOL needs. These findings support a culturally grounded approach to promote EOL planning for ethnic/racial minority groups.

Barriers of and strategies for shared decision-making implementation in the care of metastatic breast cancer: A qualitative study among patients and healthcare professionals in an Asian country

BACKGROUND

Shared decision-making has been shown to improve the quality of life in metastatic breast cancer patients in high-literacy and high-resource settings. However, limited studies have examined the cultural preferences of metastatic breast cancer patients with shared decision-making implementation and the barriers encountered in an Asian setting where societal norms predominate and physician decision-making is at the forefront. This paper aims to identify (1) barriers to practising shared decision-making faced by healthcare professionals and patients and (2) strategies for implementing shared decision-making in the context of metastatic breast cancer management in Malaysia.

METHODS

We conducted a qualitative study involving 12 patients diagnosed with metastatic breast cancer, 16 healthcare professionals and 5 policymakers from surgical and oncology departments at public healthcare centres in Malaysia. Semi-structured in-depth interviews and focus group discussions were conducted. The interviews were recorded, transcribed verbatim and analysed using the thematic approach. Nvivo software was used to manage and analyse the data.

RESULTS

Five main themes emerged from the study: healthcare provider-patient communication, workforce availability, cultural and belief systems, goals of care and paternalism versus autonomy. Other strategies proposed to overcome barriers to implementing shared decision-making were training of healthcare professionals and empowering nurses to manage patients' psychosocial issues.

CONCLUSION

This study found that practising shared decision-making in the public health sector remains challenging when managing patients with metastatic breast cancer. The utilization of decision-making tools, patient empowerment and healthcare provider training may help address the system and healthcare provider-patient barriers identified in this study.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in the study design, recruitment and analysis.

Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation

Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

Asian Americans’ Perceived Knowledge of State Vocational Rehabilitation Services for People With Mental Illness

Given the significant role of employment on independent living and well-being among individuals with disabilities, such as those with mental illness, it is important to examine the experiences of racially and ethnically diverse cultural groups, including Asian Americans. However, little research focus has been made toward Asian Americans with disabilities in the rehabilitation counseling field. This study examined knowledge of state vocational rehabilitation (VR) services and the perceived importance and likeliness of receiving VR services in a sample of 315 Asian Americans. Survey questions were developed to ask participants’ perceived importance of receiving various VR services provided within state VR agencies and the likeliness of receiving or recommending each service if they or their family members had a mental illness. The results showed that most participants were not familiar with state VR services. Although slightly different patterns were identified in the participants’ importance and likeliness ratings, the top important and preferable service was diagnosis and treatment. The information gathered in this study has important implications for crafting culturally sensitive and effective outreach and marketing strategies in Asian American communities.

Shared Decision-Making and Role Preference Among Patients With Schizophrenia in Malaysia: A Cross-Sectional Study

Introduction: Shared decision-making (SDM) is recognized as a promising strategy for improving collaboration between clinicians and their patients in achieving recovery. In Malaysia, SDM among people with schizophrenia is still lacking both in practice and in research. This study aimed to determine the level of SDM and role preference and their associated factors among patients with schizophrenia in Malaysia. Methods: A cross-sectional study was conducted on 86 outpatient attendees with schizophrenia at a teaching hospital in Kuala Lumpur, Malaysia. The nine-item Shared Decision Making Questionnaire and Control Preference Scale were used to assess perceived SDM experience and role preference, respectively. Linear and logistic regression models were used to analyze the factors associated with SDM and role preference, respectively. Factors with a p <0.25 from the simple regression analyses were controlled as the covariates in the multiple regression analyses. Results: The study respondents were predominantly female, single, and unemployed, with a mean age of 44 years. Only 35% of the participants reported having high SDM experiences, even though the majority (56%) preferred autonomous role preference. Among the participants who preferred autonomous roles, only 40% experienced high SDM. High SDM was found to be significantly associated with being younger (B = -0.33, 95% CI = -0.67 to -0.003) and being non-clozapine users (B = 19.90, 95% CI = 9.39-30.41), while autonomous role preference was significantly associated with a lower level of insight [adjusted odds ratio (AOR) = 0.84, 95% CI = 0.72-0.99] and being on oral antipsychotic drugs only (AOR = 2.94, 95% CI = 1.10-7.82). Conclusion: The practice of SDM is still lacking in the treatment of patients with schizophrenia in Malaysia, even though many of them preferred to be involved in the decision-making pertaining to their treatment. This study indicates the need for clinicians to improve their patients' involvement in the treatment process. More research is needed on how SDM can be implemented in patients with schizophrenia, especially in Asian population settings.