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Older Latinos' attitudes toward and comfort with end-of-life planning.

Advance planning provides individuals with the opportunity to discuss and plan for their own health care decisions in the event that they become seriously ill and need someone else to speak for them. The importance of providing individuals with information about end-of-life care and decision making has been documented in the literature (Gutheil & Heyman, 2005; McDonald et al., 2003). Although there is a body of literature focusing on the barriers to advance planning regarding health care decisions among different ethnic groups (Bade, Murphy, & Sullivan, 1999; Hauser, Kleefield, Brennan, & Fischbach, 1997; Morrison, Zayas, Mulvihill, Baskin, & Meier, 1998), attention to interventions developed for use with Latino populations has been minimal.

Research suggests that Latinos may not fully understand the health care proxy form or what it means to designate a health care agent (Hauser et al., 1997; Morrison et al., 1998; Romero, Lindeman, Koehler, & Allen, 1997). Furthermore, there has been little research on the effectiveness of providing end-of-life information in Spanish as one way of helping older people in their end-of-life planning. In addition, there has been little attention to including culturally relevant material in these discussions. Bonder, Martin, and Miracle (2001) noted the importance of developing culturally sensitive interventions to help Latinos in end-of-life planning. The purpose of this study was to determine which of two one-to-one educational interventions would influence Latino elders' attitudes toward and comfort with end-of-life planning when compared with a control group receiving only standard information routinely provided.

This project was grounded in Ajzen and Fishbein's (1980) theory of reasoned action, which points to the influence of social and cultural beliefs. Ajzen (2002) later built on this theory, underscoring the role of beliefs about consequences of behaviors, normative expectations, and control. Together these beliefs influence attitudes. Barclay, Blackhall, and Tulsky (2007) and Krakauer, Crenner, and Fox (2002) lent additional support to the importance of the role of culture, which represents aspects of the normative expectation noted by Ajzen (2002). These authors stated that an individual's culture may influence attitudes toward advance care planning. The role of cultural issues in comfort and attitudes about advance planning is also supported in the recent work of Arzubiaga, Artiles, King, and Harris-Murri (2008).

LITERATURE REVIEW

End-of-life planning has been used by many authors as the terminology for planning with respect to one's wishes about the end of life. Completing an advance directive is no longer the primary focus of end-of-life planning, which is now concerned more with process (Black, 2004, 2007; Teno, 1998). Although some studies have examined completion of advance directives, it is acknowledged that simply having an advance directive does not necessarily ensure that one's wishes are carried out (Ditto et al., 2001; Sansone & Phillips, 1995).

End-of-life planning is a particularly compelling issue for older adults. The literature underscores that both comfort and attitudes (Cramer, McCorkle, Cherlin, Johnson-Hurzeler, & Bradley, 2003; Gallaher & Hough, 2001; Kahana, Dan, Kahana, & Kercher, 2004) are important to facilitate discussion about difficult topics, including end-of-life concerns.

The importance of attending to the specific needs of older Latinos is highlighted by new census data. The Latino population, approximately 44 million, is now the largest minority group in the United States, surpassing African Americans (U.S. Census Bureau, 2007). Although barriers to effective end-of-life planning and care may affect anyone, language has been cited as a particular barrier for Latinos (Born, Greiner, Sylvia, Butler, & Ahluwalia, 2004; Sullivan, 2001; Wenger et al., 2001). Sullivan expressed concern that sometimes end-of-life information for Latinos is lost in translation, or communication with health care providers may not be effective because of the language barrier. A recent study to understand cultural competence (Napoles-Springer, Santoyo, Houston, Perez-Stable, 8: Stewart, 2005) found that Latinos experienced language-based discrimination related to their medical encounters.

In addition to language, the literature identifies a range of issues of importance in end-of-life planning for Latinos, including fatalism, religious--spiritual beliefs, control-autonomy, and social support. Phipps, True, and Murray (2003) pointed out that Latinos may be influenced by "fatalism (the sense that nothing can be done), which may result in not seeking treatment for some illnesses" (p. 121). Both Laws and Mayo (1998) and Luquis and Villanueva Cruz (2006) underscored the potential impact of fatalism on how Latinos deal with medical concerns. Religious, spiritual beliefs, and faith have been addressed by a number of authors (Hauser et al., 1997; Krakauer et al., 2002; Phipps et al., 2003). Gutheil and Heyman's (2006) research found that older Latinos often turned to their churches and embraced the concept of God's will.

Other researchers have examined the importance of control (Rosnick & Reynolds, 2003). Noting the role of autonomy, Gutheil and Heyman (2006) found that although some of the Latino participants wanted to rely on their families, others wanted to control their own lives. Blackhall et al. (1999) concluded from their study of different groups that ethnicity is strongly related to personal wishes about end-of-life decision making. Social support has also been identified as an important factor in end-of-life planning (Ai, Hopp, & Shearer, 2006; Rosnick & Reynolds, 2003).

The current project aimed to add to the limited intervention literature focused on older Latinos. We hypothesized that one-to-one educational intervention would influence older Latinos' attitudes toward and comfort with end-of-life planning.

METHOD

Design

This study used a posttest-only control group design. The design controls for threats to internal validity, and it is valuable when there is concern that pre-testing will influence the posttest responses:

This design assumes that the process of random assignment removes any significant initial differences between experimental and control groups.

This assumption of initial group equivalence permits the inference that any differences between the two groups at posttest reflect the causal impact of the independent variable. (Rubin & Babbie, 2008, p. 252)

Procedures

The procedures for this study received approval from the university Institutional Review Board. The study population included all Latino elders served by the two sites of a large home health care agency. Participants were excluded if they were deemed cognitively impaired. This assessment was made by the nursing supervisor at the site on the basis of her clinical judgment. The decision to use this approach was reached in consultation with other researchers in the home care field and the supervisory staff at the site agency. One hundred ninety-three potential participants were identified for the project. If two family members were served by the home care agency and therefore were on the master list of potential participants, one was randomly selected to be contacted. All of the 188 remaining eligible participants were contacted, and 109 elders agreed to participate in the study. Elders who agreed to participate were randomly assigned to one of three groups: Conversacion A (n = 37), Conversacion B (n = 36), and a control group (n = 36). For the 79 elders who did not agree to participate in the project, reasons included illness, lack of time, discomfort with the topic, and insufficient interest. Of the 109 who agreed to participate, 84 elders completed the study: Conversacion A (n = 26), Conversacion B (n = 29), and control group (n = 29).

The control group received the standard information routinely provided by the home care agency, which consisted of the New York State Health Care Proxy form and instruction booklet in Spanish and English. In addition to the standard information, Conversacion A and Conversacion B received a one-to-one protocol in their homes. These protocols provided identical basic information and took between 45 minutes to one hour to complete. During the conversation, the intervener provided information on each of the topics and engaged the individual in the discussion through dialogue and questions. Conversacion A was deemed to be moderately culturally sensitive because it was translated into and delivered in Spanish. Conversacion B was deemed intensive because, in addition to being in Spanish, it included themes identified through focus groups (see the Protocol Development section and Table 1). Material specific to the intensive protocol was introduced through statements or questions and probes. For example, the intensive intervention stated that some people prefer to rely on their doctor to make decisions regarding care and asked the individual what his or her feelings were about this (control). In discussing why it is important to plan in advance, it was noted that loved ones may not feel so great a burden if they are asked to make decisions regarding care (burden). Probes to broach the topic of family relationships included the following: concern about which child would be viewed as a favorite and concern about whether family members would agree with one person's decision.

Protocol Development

Two protocols, each designed to be administered in one individual home session, were developed (Conversacion A and Conversacion B). Conversacion B included themes identified through separate focus group sessions with Latino elders and adult children of Latino elders to identify material that they believed to be important for end-of-life discussions (Gutheil & Heyman, 2006). The protocols were reviewed by three professional social workers, two of whom were Latino, with expertise in end-of-life work, and refinements were made on the basis of the review. The protocols were translated into Spanish and then back-translated into English to confirm accuracy of the translation.

After the translation was completed, the protocols were sent back to the two Latino practitioners for their review.

Training

The interveners were all bilingual MSW social workers, trained to deliver the protocols to individuals in the home. The interveners received training from a clinical social worker with extensive gerontological experience. They were trained only on the protocol they were randomly assigned to deliver. Those who delivered Conversacion A were not aware of the additional material included in Conversacion B, which ensured that they did not inadvertently add any of this material to their discussions.

Two weeks after the protocol was delivered, a second social worker met with each elder to conduct a posttest interview to gather information about the study variables.

Measures

An instrument work group was established to determine the measures to be used in the present study. The work group reviewed the literature and held discussions with several researchers across the county who included Latinos in their studies on end-of-life issues. The instrument was pilot tested with a group of elders not connected to the research site.

The instrument work group also developed the fidelity instrument for the interveners to complete at the conclusion of their interview session. The fidelity instrument consisted of a checklist of topics for each protocol that were required to be covered to ensure consistent delivery of all protocols. The interveners were trained on using a fidelity instrument to ensure that all material was covered each time the protocol was delivered. The instrument was completed by each intervener immediately following the one-to-one session. Feedback from the interveners indicated that they found the checklist to be a helpful tool, because it was a quick method of ensuring that they remembered to cover all the essential components of the intervention. Therefore, the fidelity instrument served two functions: (1) monitoring of content coverage and (2) reminding the interveners of key points to cover. The monitoring indicated universal coverage of all required content.

Study Variables

All scales were examined for reliability and tested with confirmatory factor analysis. On the basis of this approach, the attitude, autonomy, faith, and fatalism scales were slightly modified.

Attitudes toward End-of-Life Planning. Nolan and Bruder's (1997) Attitude toward End-of-Life Planning Scale includes statements with response options ranging from strongly agree to strongly disagree. A modified 12-item scale had a Cronbach alpha of .79. Possible attitude scores range from 12 to 48, with the higher scores representing more positive attitudes toward end-of-life planning. Sample responses included the following three: (1) "I have choices about the treatment I would receive at the end-of-life." (2) "Making my end-of-life treatment wishes in writing would keep my family from disagreeing over what to do if I were very sick and unable to decide for myself." (3) "It is better to place nay end-of-life treatment wishes in writing when I am healthy."

Comfort. The Comfort Scale, developed by Gutheil and Heyman (2000), is a six-item scale which includes statements with response options ranging from very comfortable to very uncomfortable. Possible scores range from 6 to 24, with the higher scores representing more comfort in discussing end-of-life planning with the individual's doctor, someone he or she would trust to make medical decisions, or both. The Cronbach alpha for the six-item scale was .73. Sample questions included the following three: (1) "How comfortable are you talking with your doctor about treatments you do not want at the end-of-life?" (2) "How comfortable are you discussing dying with someone you would trust to make medical decisions for you?" (3) "How comfortable are you asking someone to be your health care agent?"

Autonomy. The Benjamin Rose Institute (2000) developed a measure to assess the importance of autonomy to elders, using responses ranging from not at all important to very important. The modified four-item scale had a Cronbach alpha of .67. Possible scores range from 4 to 12, with the higher score indicating greater importance of autonomy. Sample items included the following three: (1)"How important is it to do things for yourself?." (2) "How important is it to come and go as you please?" (3) "How important is it to organize your daily routines in your own way?"

Faith. Hoge's (1972) Religious Commitment Scale and two items from Williams (1999), which are commonly used in research on religion and spirituality, were combined into one measure of faith. These 10 items had a Cronbach alpha of. 80. Possible scores range from 10 to 40. Sample items included the following three: (1) "My faith involves all of my life." (2) "In my life I experience the presence of a greater being." (3) "One should seek a greater being's guidance when making important decisions."

Fatalism. The measure used for this study was based on a fatalism scale develop by Powe and Weinrich (1999) for patients with bowel cancer. After consultation with the authors of the scale, "life-threatening illness" was substituted for bowel cancer to make the scale more appropriate for this study. The modified fatalism scale had seven items with yes and no responses. The Cronbach alpha was .81. The possible scores range from 0 to 7. Sample items included the following three: (1) "I think if someone is meant to have a life-threatening illness, it doesn't matter how they take care of themselves." (2) "I think if someone has a life-threatening illness, it was meant to be." (3) "I think if someone gets a life-threatening illness, that's the way they were meant to die."

Social Support. The Multidimensional Scale of Perceived Social Support (Dahlem, Zimet, &Walker, 1991) was used to assess support from family and friends. The 12-item scale has responses ranging from very strongly disagree to very strongly agree. The scale had a Cronbach alpha of .89. The scale has possible scores ranging from 12 to 84, with higher scores indicating more social support. Sample items included the following three: (1) "There is a special person who is around when I am in need." (2) "My family really tries to help me." (3) "I can talk about my problems with my family."

Demographic and Health Variables. The following eight variables were examined: (1) age at last birthday; (2) activities of daily living (ADL), as measured by the Katz ADL scale (Katz, Ford, Moskowitz, Jackson, & Jaffee, 1963), which is used to assess ability to bathe, dress, toilet, transfer, feed self, and maintain bowel and bladder continence; (3) education, measured by highest grade completed; (4) health, measured by asking the older adults to rate their health in comparison with others their age; (5) living arrangements, to determine if they lived alone or with others; (6) marital status; (7) religion; and (8) language that participants generally read or speak, as measured by English only, Spanish only, or both English and Spanish.

Analysis Plan

This study used a posttest-only control group design to understand which of two one-to-one educational interventions would influence Latino elders' attitudes toward and comfort with end-of-life planning in comparison to a control group receiving only standard information routinely provided. All the data were entered into SPSS. First, univariate analyses were conducted. Next, bivariate analyses were conducted to assess group differences. Then a one-way multivariate analysis of variance (MANOVA) was conducted to determine the effect of the three groups on the two dependent variables: attitudes toward end-of-life planning and comfort with end-of-life planning. If there were significant differences between the groups in terms of the variables, they were included as covariates in the analysis.

RESULTS

Demographic and Health Variables

There were no significant differences with respect to age, ADLs, gender, health, marital status, or religion among the Conversacion A, Conversacion B, and control groups (see Table 2).

There were also no statistical differences among the three groups with respect to the language that participants generally read or spoke. In all three groups, the majority spoke only Spanish. The educational level for the three groups did not differ. The average grade achieved was sixth grade for each of the three groups.

There was a statistically significant difference between the groups regarding living arrangements. The control group had a higher percentage of elders living alone (75.9 percent) compared with 53.8 percent for the Conversacion A group and 41.4 percent for the Conversacion B group. Because of group differences in living arrangements, this variable was included as a covariate in the multivariate analysis.

Variables of Interest

There were no differences between groups with respect to autonomy. The actual autonomy scores were skewed, and therefore a Kruskal-Wallis test was conducted. This is a nonparametric test used when the analysis of variance (ANOVA) normality assumption is not met. There was no statistical difference in groups with respect to autonomy [[chi square] (2, N = 83) = 5.86,p > .05].

There were no statistical differences between the three groups with respect to fatalism scores [F(2, 81) = 1.23, p > .05].The Conversacion A group had a mean score of 4.62 (SD = 2.58), the Conversacion B group had a mean score of 5.48 (SD = 1.64), and the control group had a mean score of 5.14 (SD = 1.90).

There was a statistical difference between the three groups with respect to faith scores, [F(2, 81) = 6.02, p < .05]. The Conversacion A group had a mean score of 32.58 (SD = 3.62), the Conversacion B group had a mean score of 35.83 (SD = 3.35), and the control group had a mean score of 33.38 (SD = 3.96). Post hoc comparisons were conducted, indicating significant differences in the means between Conversacion A and Conversacion B as well as between the Conversacion B group and the control group. Because of group differences in faith, this variable was included as a covariate in the multivariate analysis.

There was a statistical difference in social support scores among the three groups [F(2, 81) = 3.54,p > .05].The Conversacion A group scored higher than the other two groups with respect to social support, with a mean score of 66.69 (SD = 15.17).The Conversacion B group had a mean score of 61.07 (SD = 14.76), and the control group had a mean score of 56.86 (SD = 10.88). Post hoc comparisons were conducted, indicating significant differences in the means between the Conversacion A group and the control group. Because of group differences in social support, this variable was included as a covariate in the multivariate analysis.

Regarding the dependent variables--attitude and comfort--the Conversacion A group's mean attitude score was 36.63 (SD = 4.48), the Conversacion B group's mean score was 36.72 (SD = 2.97), and the control group's mean score was 32.69 (SD = 2.98).With respect to comfort, the Conversacion A group's mean comfort score was 20.57 (SD = 3.10), the Conversacion B group's mean score was 18.93 (SD = 2.55), and the control group's mean score was 18.03 (SD = 3.10).

A one-way MANOVA was conducted to determine the effect of the three groups on the two dependent variables: attitudes toward end-of-life planning and comfort with end-of-life planning. Because there were significant differences between the groups in terms of living arrangement, faith, and social support, these factors were included as covariates in the analysis. However, they did not significantly affect group outcomes. Therefore, the results presented in Table 3 are for the analyses with these covariates omitted. Significant differences were found among the three groups on both outcome measures (attitude and comfort). ANOVAs were conducted as follow-up tests to the MANOVA. Attitudes toward end-of-life planning scores were significantly higher for both intervention groups compared with the control group. Although both intervention groups had higher comfort scores than the control group, only the Conversacion A group score was statistically different from the control groups' score. Therefore, Conversacion A influenced both attitudes toward and comfort with end-of-life planning among these Latino elders compared with the control group.

LIMITATIONS

This research demonstrates the value of a one-to-one intervention about end-of-life planning. Although this research shows that an intervention can make a difference in older Latinos' attitudes and comfort, it is not possible to tease out the relative importance of providing the intervention in the subject's language of choice and of the one-to-one conversation.

This study used a posttest-only control group design following the intervention to assess attitude and comfort. In this design, it is assumed that random assignment removes initial differences between the groups (Rubin & Babbie, 2008). Because this design is not a fully randomized controlled trial, there is no pretest that makes it possible to assess the equivalence of groups at baseline, and this is a limitation of the study. However, Campbell and Stanley (1963) underscored that "the most adequate all-purpose assurance of lack of initial biases between groups is randomization" (p. 25).

Because this study examined attitudes and comfort, there was no follow-up to determine if participants later completed a health care proxy or spoke with their families. These participants were willing to engage in a discussion of end-of-life planning. Therefore, they may be a select group. For the individuals who chose not to participate, no information is available except for the reason they declined to be involved.

The relatively small number of participants in this study is a limitation. In addition, the participants in this project had, on the whole, limited education. The average education level achieved was sixth grade. It is possible that findings may be different among older Latinos with more education. Although the study collected information on participants' health as compared with that of others their age, we did not collect information on whether the participants had a life-threatening illness, which could influence how one answers questions on the fatalism measure.

The use of the nurse's clinical judgment to assess for cognitive impairment is a limitation of this study, as is the reliance on interveners' self-reports for the fidelity measure.

DISCUSSION

The results of this study suggest that it may be possible to positively influence both attitudes toward and comfort with end-of-life planning among older Latinos receiving home care, through the use of a one-to-one protocol that is delivered in Spanish. For the older Latinos receiving home care who received the Conversacion A intervention, both attitudes toward and comfort with end-of-life planning were significantly higher than they were for participants in the control group. This protocol provided information and discussion about end-of-life planning but, although given in Spanish, did not include additional material considered culturally sensitive based on the focus groups and literature.

Although the Conversacion A protocol made a significant difference in both attitudes toward and comfort with end-of-life planning, the Conversacion B protocol was significant only with older Latinos' attitudes. This suggests there may be a point when a person is asked to reflect on too much material in a one-session intervention. In our effort to incorporate issues that are of importance to older Latinos, we may have overloaded the elders in the Conversacion B group. End-of-life planning is a difficult subject, even for those predisposed to grapple with it. It is important to respect the power of the topic and not attempt to do "everything" in one session.

As noted in the literature review, attitudes toward and comfort with end-of-life planning are important prerequisites to discussions in this area. It is possible that individuals with more positive attitudes and greater comfort may be more likely to engage in end-of-life planning. This research has demonstrated that it is possible to positively influence both of these factors when people are provided information about end-of-life planning in their language of choice. The fact that a single session devoted to a discussion of this topic can have such an impact is an important finding.

Two recommendations emerge from this study. First, because the one-to-one intervention has the potential to influence attitudes and comfort, a member of the health care team or another individual versed in end-of-life planning should carve out time to talk about these issues with elders. It is recommended that this conversation include topics such as information on advance directives; the role of the health care agent; medical, legal, and value issues; the importance of advance planning; and how to begin doing this planning. Second, for Spanish-speaking older adults, it is important to be prepared to provide discussion in Spanish. Therefore, organizations serving Latino older adults should have available bilingual staff knowledgeable about end-of-life planning, advance directives, and the range of issues that need to be addressed.

Professionals trained in end-of-life planning can provide this information to older adults. Social workers are particularly well suited to providing information about end of life. Social workers are trained in effective communication and in dealing with taboo or difficult topics with clients, as well as understanding family dynamics and the influence of systems of care. Social workers would do well to become informed about all aspects of end-of-life planning so that they are able to effectively inform clients. In addition, social workers may need to collaborate with other professionals to advocate that clients receive this information through a conversation in the language of their choice rather than by printed material alone. Even if provided in Spanish, printed material offers no possibility of dialogue and may not be written at a level that is easy to understand for individuals with limited education.

Further research can build on this project in a number of ways. For example, follow-up after older Latinos are provided information about end-of-life planning in Spanish can help determine if gains hold up over time and if older Latinos proceed to engage in end-of-life planning, have conversations with their loved ones, and make their wishes known. Studies of the use of a one-to-one intervention with other ethnic groups in the language of their choice would add to the end-of-life literature. More work is needed to address issues of end-of-life planning with culturally diverse older adults.

Original manuscript received January 29, 2008

Final revision received August 17, 2009

Accepted September 3, 2009

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Janna C. Heyman, PhD, is associate professor aim associate director Ravazzin Center on Aging, and Irene A. Gutheil, DSW, is Henry C. Ravazzin Professor of Gerontology and director; Ravazzin Center on Aging, Fordham University Graduate School of Social Service, West Harrison. NY. Address correspondence to Janna Heyman, Fordham University Graduate School of Social Service, 400 Wetchester Avenue, West Harrison, NY 10604; e-mail : heyman@fordham.edu. This research was funded by a grant from the Fall Fox & Leslie R. Samuels Foundation. Part of the research was presented At the Gerontological Society of America Conference, November 2005, Orlando, FL. The authors acknowledge, e the contributions Julio Urbina, senior program officer, Fan Fox & Leslie R. Samuels Foundation; Chris Kinon, and Karen Dybing. As a result of this research, the authors have developed a booklet titled A Blueprint for Discussing, the Health Care Proxy/ Un Anterpoyecto Para Discutir Sobere El Poder Pare La Atencion Medica. This protocol (Conversacion A) is available in both English and Spanish by accessing the "Publications and Conferences" page of the Ravazzin Center on Aging Web site: www.fordham.edu/ravazzin.
Table 1: Topics included in Protocols

Topics: Conversacion A and Conversacion B

* Advance directives
  ** Health care proxy
  ** Living will
* Role of the health care agent
* Importance of advance planning
* Medical, legal, and value issues
* How to begin a conversation with loved ones

Additional Topics: Conversacion B

* Burden--for example, burden of decision making on
  loved one
* Control--for example, making own decision or relying on
  others
* Communication and lack of communication
* Importance of family relationships
* Religion
* Spirituality

Table 2: Comparison of Group Demographics

                       Conversacion A   Conversacion A   Conversacion A
                          (n = 26)         (n = 26)         (n = 26)

Variable                 n       %        n       %        n       %

Gender
  Male                   6     23.1       3     10.3       5     17.2
  Female                20     76.9      26     89.7      24     82.8
Age range (years)
  50-59                  4     15.4       0      0.0       1      3.4
  60-69                  5     19.2       6     20.7      11     37.9
  70-79                  9     34.6      12     41.4       9     31
  80+                    8     30.8      11     37.9       8     27.6
  M                            71.7             75.93            73.48
  SD                           10.7              6.70            10.61
Marital status
  Married                7     26.9       6     20.7       1      3.4
  Divorced/separated     5     19.2       6     20.7      15     51.7
  Widowed                9     34.6      15     51.7       7     24.1
  Single                 5     19.2       2      6.9       6     20.7
Live alone
  Yes                   14     53.8      12     41.4      22     75.9
  No                    12     46.2      17     58.6       7     24.1
Religion
  Catholic              21     80.8      22     75.9      23     79.3
  Protestant             4     15.4       7     24.1       5     17.2
  Other                  1      3.8       0      0         1      3.4
No. ADLs (a)
  0                     12     46.2      10     34.5      13     44.8
  1-2                   11     42.3      13     44.8      10     34.5
  3+                     3     11.5       6     20.7       6     20.7
Health
Excellent/very good      3     11.5       2      6.9       2      6.8
  Good                  13     50.0      15     51.7      10     34.5
  Fair                   9     34.6      12     41.4      10     34.5
  Poor                   1      3.8       0      0         7     24.1
Education (years)
  0-4                   11     44.0      12     41.4      10     35.7
  5-8                    5     20.0      11     37.9      11     39.3
  9-12                   9     36.0       4     13.8       5     17.9
  13-16                  0      0         2      7         2      7.1

Activities of daily living (ADLs) is expressed as a number score
ranging from a low of zero to a high of six, with higher scores
indicating a greater need for help with ADLs.

Table 3: Mean Attitude and Comfort Scores for Participants

                            Attitude toward          Comfort with
                          End-of-Life Planning   End-of-Life Planning

                              M          SD          M          SD

Conversacion A (n = 26)   36.63 **      4.48     20.57 ***     3.10
Conversacion B (n = 29)   36.72 **      2.97     18.93         2.55
Control Group (n = 29)    32.69 **      2.98     18-03 ***     3.10

(a) Wilks' A of .72 is significant [F(4, 160) = 7.23, p < .0011,
indicating that we can reject the hypothesis that the population means
on the dependent variables are the same for the three types of groups.

** The univariate analysis of variance (ANOVA) for attitude scores
indicated that both the Conversacion A and the Conversacion 3 groups
scored statistically significantly higher than the control group [F(2,
81) = 12.27, p < .001].

*** The univariate ANOVA for comfort was statistically significantly
different between the Conversacion A and the Control groups, with
Comfort scores being higher for the Conversacion A intervention group
[F(2, 81) = 5.30, p < .01].
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