key: cord-1020710-403b3o45 authors: Okpalauwaekwe, Udoka; Li, Chih-Ying; Tzeng, Huey-Ming title: Social Determinants and Self-Care for Making Good Treatment Decisions and Treatment Participation in Older Adults: A Cross-Sectional Survey Study date: 2022-03-10 journal: Nurs Rep DOI: 10.3390/nursrep12010020 sha: 8be0ec19e590aad58fabe14289534f2d2899d177 doc_id: 1020710 cord_uid: 403b3o45 Background: Community-dwelling adults who can perform self-care behaviors related to making treatment decisions and participating in treatment have been found to use less emergency care. In this exploratory study, we examined the relationships in older adults between five social determinants (urban/rural residence, sex, age, marital status, and education) and the perceived importance, desirability, and ability to perform 11 self-care behaviors related to making good treatment decisions and participating in treatment. Methods: This cross-sectional study surveyed 123 community-dwelling older adults living in the southern United States in 2015–2016. All participants were 65 years or older. Data were collected using the Patient Action Inventory for Self-Care and analyzed using descriptive, univariate, and multivariate logistic regression analyses. Results: The social determinants (identified as barriers) of self-care behaviors related to making good treatment decisions and participating in treatment were: having less than a high school education, being 75 years or older, and being separated from a spouse. Sex and residence were found to be neither barriers nor facilitators. Conclusions: Our findings suggest that, in older adults, attending to the needs related to health literacy education and improving social support might increase self-care behaviors related to making good treatment decisions and participating in treatment. Future research will compare the differences across diverse populations to validate our study findings. The U.S. Agency for Healthcare Research and Quality recommends that the effective engagement of patients in their self-care improves health outcomes, patient satisfaction, and overall quality of life [1] . This patient-centered approach to healthcare advocates for a patient's involvement in making good treatment decisions while participating in their treatment through shared decision-making [1] . Shared decision-making is the process in which a healthcare treatment choice is made jointly between the patient (and/or family member) and one or more healthcare professionals [2] . Power imbalances in patientclinician relationships and the perception of patient participation acceptability on the part of clinicians are often cited as barriers to engaging patients in shared decision-making [3, 4] . Although decision aids have been shown to help support patients in shared decisionmaking processes, most older adult patients need both the knowledge and the power to actively engage in decision-making about their treatment plans [3] . Hence, recent studies have recommended adding patient engagement and self-care activities to the process [5] [6] [7] [8] . Events brought about by the ongoing global COVID-19 pandemic have no doubt informed the need for a patient-centered approach to promoting self-care for older adults. Health challenges and disparities have clearly been amplified by the advent of COVID-19, especially in the more aged population. The U.S. Centers for Disease Control and Prevention reported that adults 65 years and older are more likely than those of other age groups to die or develop a severe illness leading to hospitalization if they contract the coronavirus [9] , which resulted in recommendations for older adults to stay at home and avoid close contact with others. Already, several studies have reported on the compounding health conditions among older adults-anxiety, depression, loneliness, increasing comorbidities, and the worsening of existing chronic diseases-brought about as they were considered the most vulnerable to COVID-19 [10] [11] [12] [13] [14] . These studies also implied that older adults desired a sense of control and preparedness to make medical decisions involving their care [10, 11, 15, 16] . The World Health Organization defines self-care as "the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider" [17] . Assessing the ability of older adults to handle self-care is a common barrier to engaging older adults in making good treatment decisions or participating in their care [2] . The notion that older adults are frail and vulnerable tends to challenge their active involvement in self-care and often relegates their care to nursing homes designed to provide more attention and care support. Contrarily, a few studies have shown that most older adults above the age of 65 consider themselves active and in better physical and psychological health than labels often suggest [8, 10, 18] . A recent survey of more than 1000 older adults in Western Canada exploring the question "What suggestions can you make to engage someone in their health and healthcare?" indicated that older adults wanted to be engaged as partners in their care in ways that enhance feasible healthcare access and autonomy in making decisions [8] . Another recent U.S. study [19] found that community-dwelling adults (53.7% of whom were 65 years and older) who reported being able to perform the self-care behaviors of knowing about any interactions between their old and new treatments, talking with their providers when stopping treatment, and tracking their symptoms and health measures, were less likely to have visited the emergency department in the preceding three months. Yet, how the demographic social determinants of older adults affected their ability to perform self-care behaviors related to making good treatment decisions and participating in their treatment was unclear. A literature search for peer-reviewed journal articles showed that, compared with other counterparts, older adult men, married individuals, and individuals with a more advanced education were more likely to participate in shared decision-making self-care practices actively [3, [20] [21] [22] . Advancing age was demonstrated in other studies to be a facilitator [23] or a barrier [24] [25] [26] to performing shared decision-making. Geographic location and residential setting were not associated with older adults' self-care capacity to participate in shared decision-making or treatment [3, [20] [21] [22] . To be able to develop practical solutions addressing the unique needs of older adults, we aimed to improve our understanding of the demographic, social determinants associated with their treatment decision-making and participation in treatment. In this exploratory study, we examined the relationships between five demographic variables of older adults (urban or rural residence, sex, age, marital status, and education level) and the perceived importance, desirability, and ability to perform 11 self-care behaviors related to making good treatment decisions and participating in their treatment. This study used data from a cross-sectional survey of community-dwelling adults living in the southern United States in 2015-2016. The project was approved by the Tennessee Technological University and the University of Saskatchewan institutional review boards. This manuscript complies with STROBE guidelines (https://www.equator-network.org/ reporting-guidelines/strobe/, accessed on 7 March 2022). A detailed description of the methods used in the study has been published [19, 27] . Convenience sampling was used to recruit healthy community-dwelling adult participants 18 years and older living in the region. Eight seniors' centers and the student health service at Tennessee Technological University were surveyed. The targeted sample size was 250. Responses from participants 65 years and older (N = 123) were used for the present study. The self-administered survey included two tools: The Patient Action Inventory for Self-Care This tool was developed and validated by Tzeng and Pierson [27] based on the Engagement Behavior Framework developed by the Center for Advancing Health [28] . It encompasses 52 patient engagement behaviors grouped into 10 categories. The Cronbach alpha for the tool as a whole was 0.968 [27] . For this study, we focused on 2 of the 10 categories: "making good treatment decisions" and "participating in treatment." Participants were asked to select "yes" or "no" for each behavior statement from three perspectives: Is this important to you? Do you want to do this? Are you able to do this? Participant responses related to the 11 self-care behaviors (outcome variables) from among the 52 behaviors inventoried were analyzed: Seeking more than one expert opinion for the treatment of illness when needed; Asking about the good and bad outcomes of suggested treatments; Working with your provider(s) on your treatment plan; Knowing side effects before starting new treatments; Knowing how old and new treatments interact; Filling or refilling prescriptions on time; Keeping track of the outcomes of your treatments; Talking with your provider(s) when stopping your treatment; Maintaining all of your health devices; Discussing why tests are ordered before getting them done, and; Tracking your symptoms and health measures. Demographic Questionnaire This tool was used to gather information on age group (65 to <75 years, 75 to <85 years, and ≥85 years), sex (male and female), marital status (married, single, or separated), residential setting (urban or rural), and education level (