Community-based game intervention to improve South Asian Indian Americans’ engagement with advanced care planning

ABSTRACT

Objective: Advance care planning (ACP) allows individuals to express their preferences for medical treatment in the event that they become incapable of making their own decisions. This study assessed the efficacy of a conversation game intervention for increasing South Asian Indian Americans’ (SAIAs’) engagement in ACP behaviors as well as the game’s acceptability and cultural appropriateness among SAIAs.

Design: Eligible community-dwelling SAIAs were recruited at SAIA cultural events held in central Texas during the summer of 2016. Pregame questionnaires included demographics and the 55-item ACP Engagement Survey. Played in groups of 3–5, the game consists of 17 open-ended questions that prompt discussions of end-of-life issues. After each game session, focus groups and questionnaires were used to examine the game’s cultural appropriateness and self-rated conversation quality. Postintervention responses on the ACP Engagement Survey and rates of participation in ACP behaviors were collected after 3 months through phone interviews or online surveys. Data were analyzed using descriptive statistics, frequencies, and paired t-tests comparing pre/post averages at a .05 significance level.

Results: Of the 47 participants, 64% were female, 62% had graduate degrees, 92% had lived in the U.S. for >10 years, 87% were first-generation immigrants, and 74% had no advance directive prior to the game. At the 3-month follow-up, 58% of participants had completed at least one ACP behavior, 42% had discussed end-of-life issues with loved ones, 15% did so with their healthcare providers, and 18% had created an advanced directive. ACP Engagement Survey scores increased significantly on all four of the process subscales by 3 months postgame.

Conclusion: SAIA individuals who played a conversation game had a relatively high rate of performing ACP behaviors 3 months after the intervention. These findings suggest that conversation games may be useful tools for motivating people from minority communities to engage in ACP behaviors.

KEYWORDS:

• Advanced care planning
• game
• South Asian
• intervention
• end-of-life discussion
• living will
• healthcare proxy

Acknowledgments

The authors would like to acknowledge Nick Jehlen, Rob Peagler, and Jethro Heiko of Common Practice (formerly The Action Mill, LLC) for their permission to use the game My Gift of Grace for the purposes of this study.

We would also like to acknowledge community members Radhakrishnan and Subbalaxmi Subramanian for their guidance and their efforts to increase awareness about the study within the South Asian Indian community in central Texas.

Editorial support with manuscript development was provided by John Bellquist from the Cain Center for Nursing Research and the Center for Transdisciplinary Collaborative Research in Self-management Science (P30, NR015335) at The University of Texas at Austin School of Nursing.

Disclosure statement

No potential conflict of interest was reported by the authors.

Key messages:

1. South Asian Indian Americans have a low rate of engagement in advanced care planning behaviors.

2. This is the first study to establish the feasibility of using a conversation game to engage the U.S. minority community of SAIAs in enjoyable, satisfying, realistic group discussions about ACP.

3. The community-based conversation game intervention increased SAIAs’ participation in ACP behaviors by 58%, three months after the intervention.

4. Games may be useful tools for motivating people from minority communities to engage in ACP behaviors such as discussion of the sensitive topic of end-of-life care and completion of advance directives.

5. Future studies should evaluate the efficacy of games in affecting SAIA individuals’ engagement in ACP behaviors using a randomized controlled trial design.

Additional information

Funding

This study was funded by the University of Texas Austin School of Nursing and St. David’s Center for Health Promotion & Disease Prevention Research in Underserved Populations.