Racial and Ethnic Disparities in Advance Care Planning: Assessing the Role of Subjective Life Expectancy

OBJECTIVES

Persistent race disparities in advance care planning (ACP) are troubling, given Black and Hispanic older adults' elevated risk of disease, some dementias, and receipt of care that may not align with their preferences. A potentially important yet underexplored explanation for these disparities is subjective life expectancy (SLE), or beliefs about one's future survival which may impel or impede ACP.

METHODS

Data are from the Health and Retirement Study (HRS; n=8,912). We examined the extent to which perceived chances of living another 10 years are associated with three components of ACP (living will, durable power of attorney for health care [DPAHC], and informal discussions). We used multilevel logistic regression models to evaluate the extent to which SLE mediates the association between race and ACP, adjusting for demographic, socioeconomic, psychosocial, and health characteristics.

RESULTS

Black and Hispanic older adults have significantly lower rates of ACP relative to whites. These disparities persist even when SLE is controlled. Blacks report especially optimistic whereas Hispanics report pessimistic survival expectations, although these differences do not explain racial disparities in ACP. SLE has direct effects on ACP, such that persons who report an "uncertain" SLE are less likely to have a living will or a DPAHC, whereas those who perceive a 50 percent chance of survival have significantly greater odds of discussions, relative to those who perceive a 0 percent chance of survival.

DISCUSSION

Doctor-patient conversations about the likely course of one's illness may inform patients' knowledge of their SLE, which may motivate timely ACP.

How do the particular characteristics of less-educated employees with disabilities impact survey implementation?

BACKGROUND

Employees with disabilities make up a significant share of the working population. The group of employees covered by this study is hard to include in research and yet must be researched due to the vulnerable position it holds in the labour market. The topic is quite complex.

OBJECTIVE

The article's main goal is to demonstrate how to implement a survey and adapt a questionnaire for assessing competencies and motivation for training and career changes among older and less-educated employees who have disabilities.

METHODS

In the paper, we discuss the approach to adapting a questionnaire and a survey by undertaking an extensive process of different testing and adaptation stages that is presented in the article.

RESULTS

We highlight some obstacles that employees with disabilities face when participating in surveys due to their low literacy skills, as well as low self-esteem, accessibility issues and other general methodological issues in the context of our population. Potential solutions gathered from all phases of the adaptation process are discussed.

CONCLUSIONS

Proper survey implementation and questionnaire modification must be ensured if researchers aim to increase the willingness of individuals with disabilities to participate in the survey and to gather quality results.

Impact of the Terms "Regular" or "Pasable" as Spanish Translation for "Fair" of the Self-Rated Health Question Among US Latinos: A Randomized Experiment

Objectives. To examine measurement comparability of a Spanish version of self-rated health (SRH) with pasable as an alternative to regular for the response category "fair" in the English version.Methods. We translated "fair" into 2 Spanish versions: regular and pasable. We implemented a split-half experiment in 3 surveys independently conducted from October 2015 to January 2016, from April to November 2016, and from August to November 2017. Within each survey, we randomly assigned Spanish-interviewed Latino respondents to 1 of the 2 SRH versions. The total sample included 3261 Latino and 738 non-Latino White adults in the United States.Results. Spanish-interviewed Latinos reported substantively more favorable health on SRH with pasable than with regular. When pasable instead of regular was used for SRH, we observed a larger difference between respondents reporting positive versus negative SRH on objective health measures, including the frequency of doctor's visits. Furthermore, when we accounted for correlates of health, Latino-White disparities were attenuated with pasable.Conclusions. We recommend using pasable instead of regular for SRH Spanish translations to improve measurement equivalence in cross-lingual and cross-cultural research.

Depression Fully Mediates the Effect of Multimorbidity on Self-Rated Health for Economically Disadvantaged African American Men but Not Women

Background. Although chronic medical conditions (CMCs), depression, and self-rated health (SRH) are associated, their associations may depend on race, ethnicity, gender, and their intersections. In predominantly White samples, SRH is shown to better reflect the risk of mortality and multimorbidity for men than it is for women, which suggests that poor SRH among women may be caused not only by CMCs, but also by conditions like depression and social relations-a phenomenon known as "the sponge hypothesis." However, little is known about gender differences in the links between multimorbidity, depression, and SRH among African Americans (AAs). Objective. To study whether depression differently mediates the association between multimorbidity and SRH for economically disadvantaged AA men and women. Methods. This survey was conducted in South Los Angeles between 2015 to 2018. A total number of 740 AA older adults (age ≥ 55 years) were enrolled in this study, of which 266 were AA men and 474 were AA women. The independent variable was the number of CMCs. The dependent variable was SRH. Age and socioeconomic status (educational attainment and marital status) were covariates. Depression was the mediator. Gender was the moderator. Structural Equation Modeling (SEM) was used to analyze the data. Results. In the pooled sample that included both genders, depression partially mediated the effect of multimorbidity on SRH. In gender specific models, depression fully mediated the effects of multimorbidity on SRH for AA men but not AA women. For AA women but not AA men, social isolation was associated with depression. Conclusion. Gender differences exist in the role of depression as an underlying mechanism behind the effect of multimorbidity on the SRH of economically disadvantaged AA older adults. For AA men, depression may be the reason people with multimorbidity report worse SRH. For AA women, depression is only one of the many reasons individuals with multiple CMCs report poor SRH. Prevention of depression may differently influence the SRH of low-income AA men and women with multimorbidity.

Adverse Childhood Experiences Among Hispanic Children in Immigrant Families Versus US-Native Families

OBJECTIVES

To examine the prevalence of child and family characteristics associated with adverse childhood experiences (ACEs) in Hispanic children in immigrant families compared with Hispanic children in US-native families.

METHODS

Data were from the nationally representative 2011-2012 National Survey of Children's Health. Parent-reported child ACE exposure was classified as no ACEs (0), low ACEs (1), or high ACEs (≥2). By using multinomial logistic regression, we evaluated the odds of low or high ACE exposure versus no ACE exposure by immigrant family status and child and family characteristics (eg, insurance status, child health status, or household-to-income ratio).

RESULTS

The study sample included 12 162 Hispanic children. More children in immigrant families lived ≤200% of the federal poverty level compared with children in US-native families (80% vs 47%, respectively; P < .001). Thirty percent of children in US-native families reported high ACEs compared with only 16% of children in immigrant families (P < .001). The odds of high ACE exposure versus no ACE exposure for children in immigrant families compared with US-native children was 0.46 (95% confidence interval: 0.34-0.61). Child and family characteristics did not explain the difference in odds of ACE exposure by immigrant family status.

CONCLUSIONS

Children in immigrant families had significantly lower odds of ACE exposure despite higher prevalence of poverty. This may not reflect a true health advantage in this population. There may be unmeasured factors that buffer children in immigrant families from ACE exposure, or ACE questions may not capture the adverse experiences specific to immigrant families.

Relationship between Future Time Orientation and Item Nonresponse on Subjective Probability Questions: A Cross-Cultural Analysis

Time orientation is an unconscious yet fundamental cognitive process that provides a framework for organizing personal experiences in temporal categories of past, present and future, reflecting the relative emphasis given to these categories. Culture lies central to individuals' time orientation, leading to cultural variations in time orientation. For example, people from future-oriented cultures tend to emphasize the future and store information relevant for the future more than those from present- or past-oriented cultures. For survey questions that ask respondents to report expected probabilities of future events, this may translate into culture-specific question difficulties, manifested through systematically varying "I don't know" item nonresponse rates. This study drew on the time orientation theory and examined culture-specific nonresponse patterns on subjective probability questions using methodologically comparable population-based surveys from multiple countries. The results supported our hypothesis. Item nonresponse rates on these questions varied significantly in the way that future-orientation at the group as well as individual level was associated with lower nonresponse rates. This pattern did not apply to non-probability questions. Our study also suggested potential nonresponse bias. Examining culture-specific constructs, such as time orientation, as a framework for measurement mechanisms may contribute to improving cross-cultural research.

Ethnic variation in self-rated health-mortality association: Results from a 17-year follow-up study in Estonia

BACKGROUND AND AIM

Previous research has highlighted the role of self-rated health (SRH) as an important predictor of mortality. With substantial ethnic differences in SRH and mortality reported in Estonia, this study aims to examine the ethnic variation in SRH-mortality association in this setting.

MATERIALS AND METHODS

The baseline data come from the nationally representative 1996 Estonian Health Interview Survey. Individual records of 3983 respondents in the 25-79 age group were linked with mortality data with 17 years follow-up time. The association between SRH and all-cause mortality was analyzed using the Cox regression for two ethnic groups and separately for men and women.

RESULTS

Among ethnic Estonians, both men and women with bad or very bad SRH had about 60% higher mortality compared to those with good or very good SRH even after adjustment for age, socioeconomic and health-related variables. In contrast, SRH did not predict mortality among non-Estonian men and women. A strong and universal inverse association with mortality was found for personal income. Education (among men) and occupation (among women) predicted mortality only among non-Estonians, whereas ever smoking was associated with mortality in Estonian men and women. Overweight women had lower mortality risk compared to women in normal weight category.

CONCLUSIONS

We found considerable ethnic variation in SRH-mortality association and in socioeconomic predictors of mortality. Further research, preferably focusing on cause-specific mortality and reporting heterogeneity of SRH could potentially shed further light on ethnic differences in SRH-mortality association in Estonia and more generally on socioeconomic inequalities in mortality in Eastern Europe.

The Relationship Between Self-Rated Health and Acculturation in Hispanic and Asian Adult Immigrants: A Systematic Review

We systematically reviewed studies to identify the association between acculturation and self-rated health (SRH) and the impact of nativity and language use in Asian and Hispanic adult immigrants. Six electronic databases were searched. Data on nativity and limited English proficiency (LEP) was extracted and analyzed. Nine studies met review criteria. A positive association between acculturation and fair/poor SRH among Asians and Hispanics was found. For both Asians and Hispanics, six out of eight studies showed nativity and all three studies reporting LEP were associated with worse SRH compared to whites. Nativity and LEP were found to be risk factors for reporting worse SRH in Hispanics compared to Asians. The degree of association between nativity and LEP and worse SRH was found to vary by Asian and Hispanic subgroup. Further studies are needed to accurately assess the health status of these populations, which will be essential to eliminating disparities.

Research in and Prospects for the Measurement of Health Using Self-Rated Health

Self-rated health (SRH)-for example, "in general would you say your health is excellent, very good, good, fair, or poor?"-is the most widely used measure of health across a range of survey research studies. This paper synthesizes extant research and provides a framework for future research on the measurement of health using SRH, focusing on four interrelated topics: the factors that influence respondents' health ratings, the survey measurement features of SRH, how SRH answers are analyzed, and the stated purpose of SRH as a proxy for more objective health or as a perception of health. Extant research on the health, psychological, and social factors influencing respondents' SRH answers is reviewed, as is research concerned with the survey measurement features of SRH that influence how respondents rate their health. The synthesis proposes a framework for future research that focuses on further explicating the factors that underlie respondents' SRH answers and improving features of SRH measurement and analysis in ways that are consistent with the various goals of the researchers who both collect and analyze the data.

Assessing the potential to combine attitude tracking and health campaign evaluation surveys

Issue addressed: Online surveys are becoming increasingly popular in health research because of the low cost and fast completion time. A large proportion of online survey costs are allocated to setup and administration expenses, which suggests that conducting fewer, longer surveys would be a cost-effective approach. The current study assessed whether the incorporation of a health campaign evaluation survey within a longitudinal attitudes and behaviours tracking survey produced different outcomes compared with the separate administration of the evaluation survey.Methods: Data were collected via an online panel, with 688 respondents completing the combined survey and 657 respondents completing the evaluation-only survey. Regression analyses were conducted to examine whether survey type was related to the campaign evaluation results.Results: Those who completed the combined survey perceived the campaign advertisement to be more personally relevant than those completing the evaluation-only survey. There were no differences in results relating to campaign awareness and reported behavioural change as a result of campaign exposure.Conclusions: There were minimal differences between results obtained from combining an attitude/behaviour tracking survey with a campaign evaluation survey. Any priming or order effects were limited to respondents' cognitive responses to the advertisement.So what?: The results suggest that health practitioners with limited resources available for tracking and evaluation research may be able to maximise outcomes by administering fewer, longer surveys.

Methodological Aspects of Subjective Life Expectancy: Effects of Culture-Specific Reporting Heterogeneity Among Older Adults in the United States

OBJECTIVES

Subjective life expectancy (SLE) has been suggested as a predictor of mortality and mortality-related behaviors. Although critical for culturally diverse societies, these findings do not consider cross-cultural methodological comparability. Culture-specific reporting heterogeneity is a well-known phenomenon introducing biases, and research on this issue with SLE is not established.

METHOD

Using data from the Health and Retirement Study, we examined reporting heterogeneity in SLE focusing on item nonresponse, focal points, and reports over time for five ethnic-cultural groups: non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic other races, English-interviewed Hispanics, and Spanish-interviewed Hispanics.

RESULTS

On item nonresponse, Spanish-interviewed Hispanics said, "I don't know," to SLE significantly more than any other groups. Nearly half of the respondents chose 0, 50, or 100, making them focal points. However, the focal points differed: 50 for Whites, 100 for Blacks, and 0 for Spanish-interviewed Hispanics. The relationship of SLE measured at two time points was higher for Whites than minorities. Moreover, those who said "I don't know" to SLE showed higher subsequent mortality than those who gave an answer. SLE was not a significant mortality predictor for Hispanics.

DISCUSSION

Overall, SLE is not free from culture-specific reporting heterogeneity. This warrants further research about its culture-relevant measurement mechanisms.

Variations in Health-Related Quality of Life (HRQoL) and survival 1 year after stroke: five European population-based registers

OBJECTIVE

There were two main objectives: to describe and compare clinical outcomes and Patient-Reported Outcome Measures (PROMs) collected using standardised procedures across the European Registers of Stroke (EROS) at 3 and 12 months after stroke; and to examine the relationship between patients' Health-Related Quality of Life (HRQoL) at 3 months after stroke and survival up to 1 year across the 5 populations.

DESIGN

Analysis of data from population-based stroke registers.

SETTING

European populations in Dijon (France); Kaunas (Lithuania); London (UK); Warsaw (Poland) and Sesto Fiorentino (Italy).

PARTICIPANTS

Patients with ischaemic or intracerebral haemorrhage (ICH) stroke, registered between 2004 and 2006.

OUTCOME MEASURES

(1) HRQoL, assessed by the physical component summary (PCS) and mental component summary (MCS) of the Short-Form Health Survey (SF-12), mapped into the EQ-5D to estimate responses on 5 dimensions (mobility, activity, pain, anxiety and depression, and self-care) and utility scores. (2) Mortality within 3 months and within 1 year of stroke.

RESULTS

Of 1848 patients, 325 were lost to follow-up and 500 died within a year of stroke. Significant differences in mortality, HRQoL and utility scores were found, and remained after adjustments. Kaunas had an increased risk of death; OR 2.34, 95% CI (1.32 to 4.14) at 3 months after stroke in Kaunas, compared with London. Sesto Fiorentino had the highest adjusted PCS: 43.54 (SD=0.96), and Dijon had the lowest adjusted

MCS

38.67 (SD=0.67). There are strong associations between levels of the EQ-5D at 3 months and survival within the year. The trend across levels suggests a dose-response relationship.

CONCLUSIONS

The study demonstrated significant variations in survival, HRQoL and utilities across populations that could not be explained by stroke severity and sociodemographic factors. Strong associations between HRQoL at 3 months and survival to 1 year after stroke were identified.

The effects of response option order and question order on self-rated health

OBJECTIVES

This study aims to assess the impact of response option order and question order on the distribution of responses to the self-rated health (SRH) question and the relationship between SRH and other health-related measures.

METHODS

In an online panel survey, we implement a 2-by-2 between-subjects factorial experiment, manipulating the following levels of each factor: (1) order of response options ("excellent" to "poor" versus "poor" to "excellent") and (2) order of SRH item (either preceding or following the administration of domain-specific health items). We use Chi-square difference tests, polychoric correlations, and differences in means and proportions to evaluate the effect of the experimental treatments on SRH responses and the relationship between SRH and other health measures.

RESULTS

Mean SRH is higher (better health) and proportion in "fair" or "poor" health lower when response options are ordered from "excellent" to "poor" and SRH is presented first compared to other experimental treatments. Presenting SRH after domain-specific health items increases its correlation with these items, particularly when response options are ordered "excellent" to "poor." Among participants with the highest level of current health risks, SRH is worse when it is presented last versus first.

CONCLUSION

While more research on the presentation of SRH is needed across a range of surveys, we suggest that ordering response options from "poor" to "excellent" might reduce positive clustering. Given the question order effects found here, we suggest presenting SRH before domain-specific health items in order to increase inter-survey comparability, as domain-specific health items will vary across surveys.