1. State your health outcome of interest. (It could be the one you used for week #2 or another one.) Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention. (If none of the behaviors in the readings are important for your health outcome, suggest another behavior that is.)
Health outcome of interest: Engagement in the process of advance care planning (e.g. choosing a surrogate decision maker, or talking with loved ones and clinicians about the medical care they would want if they were to become too ill to speak for themselves).
Key Health behaviors: Healthcare utilization, Decision Control Preferences
Healthcare utilization has been linked to health behaviors such as screening and preventative care. Since advance care planning (ACP) has been conceptualized as a health behavior, it is possible that patients who have higher levels of healthcare utilization will also have higher levels of engagement in ACP.
Decision control preferences (DCP) refer to the amount of control patients prefer to have over their medical decisions. Preferences can range from wanting to make all their own medical decisions, (high DCP) sharing decision making equally with clinicians, or having clinicians make all their medical decisions (low DCP). The prevalence of low DCP is estimated to be around 20% and has been found to associated with older age and lower readiness to engage in health behaviors. Therefore, engagement in ACP may depend on a patient’s decision control preferences.
2. Describe how you would study the role of one of the behaviors described for question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
In our current efficacy trial of a new advance care planning website, we assess both a participant’s engagement as well as their decision control preferences.
Decision control preferences (DCP) can be assessed by a simple question: “How do you prefer to make your medical decisions with your doctors?” on a five point Likert scale:
1. I make all my own medical decisions
2. I listen to my doctor’s opinion, but I make the final decision
3. My doctor and I share decision making equally
4. The doctor listens to my opinion, but the doctor makes the final decision
5. My doctor makes all my medical decision
Engagement in advance care planning is measured by a validated tool for older adults with serious or chronic illness (ACP Engagement Survey).
For the social factor, race and ethnicity have been shown to impact decision control preferences. The concept of autonomy in medical decision making often has cultural values attached to it. To incorporate this in the study approach, you would need to collect race/ethnicity information and compare the levels of DCP to the different groups.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes? Why or why not?
These key health behaviors of smoking, exercise, and diet are modifiable. So, even though they are influenced by neighborhood, income, and education, measuring and studying these modifiable behaviors are an important opportunity to improve outcomes. Furthermore, behaviors such as smoking, exercise, and diet are more easily modifiable than one’s neighborhood, income, or education level. Therefore, the opportunity for intervention would be within those behaviors and they must be studied.