Are Asians comfortable with discussing death in health valuation studies? A study in multi-ethnic Singapore

Hwee-Lin Wee,Xu-Hao Zhang,Yin-Bun Cheung,Shu-Chuen Li,Nan Luo,Feng Xie,Kok-Yong Fong,David Machin,Julian Thumboo

doi:10.1186/1477-7525-4-93

Abstract

BackgroundTo characterize ease in discussing death (EID) and its influence on health valuation in a multi-ethnic Asian population and to determine the acceptability of various descriptors of death and "pits"/"all-worst" in health valuation.MethodsIn-depth interviews (English or mother-tongue) among adult Chinese, Malay and Indian Singaporeans selected to represent both genders and a wide range of ages/educational levels. Subjects rated using 0–10 visual analogue scales (VAS): (1) EID, (2) acceptability of 8 descriptors for death, and (3) appropriateness of "pits" and "all-worst" as descriptors for the worst possible health state. Subjects also valued 3 health states using VAS followed by time trade-off (TTO). The influence of sociocultural variables on EID and these descriptors was studied using univariable analyses and multiple linear regression (MLR). The influence of EID on VAS/TTO utilities with adjustment for sociocultural variables was assessed using MLR.ResultsSubjects (n = 63, 35% Chinese, 32% Malay, median age 44 years) were generally comfortable with discussing death (median EID: 8.0). Only education significantly influenced EID (p = 0.045). EID correlated weakly with VAS/TTO scores (range: VAS: -0.23 to 0.07; TTO: -0.14 to 0.11). All subjects felt "passed away", "departed" and "deceased" were most acceptable (median acceptability: 8.0) while "sudden death" and "immediate death" were least acceptable (median acceptability: 5.0). Subjects clearly preferred "all-worst" to "pits" (63% vs. 19%, p < 0.001).ConclusionSingaporeans were generally comfortable with discussing death and had clear preferences for several descriptors of death and for "all-worst". EID is unlikely to influence health preference measurement in health valuation studies.

Highlights

To characterize ease in discussing death (EID) and its influence on health valuation in a multi-ethnic Asian population and to determine the acceptability of various descriptors of death and "pits"/"all-worst" in health valuation
The topic of death is invariably raised in such studies as subjects are required to value death either directly, for example, when visual analogue scales (VAS) are used or indirectly, for example, when time trade-off (TTO) or standard gamble (SG) are used [2]
We studied the influence of EID on VAS/TTO utilities with and without adjustments for sociocultural variables, as this could impact on health preferences and might need to be adjusted for in health valuation studies

Summary

Introduction

To characterize ease in discussing death (EID) and its influence on health valuation in a multi-ethnic Asian population and to determine the acceptability of various descriptors of death and "pits"/"all-worst" in health valuation. Reluctance to discuss death may potentially reduce participation in health valuation studies, resulting in selection bias. It may increase the prevalence of missing valuation data for the health state of being dead, which is problematic because these values are required to rescale raw scores onto a 0 (dead) to 1 (perfect health) scale [7]. These missing values would render other associated data unusable, resulting in significant data wastage [8]. Reluctance to discuss death may be relevant in an Asian population, where, for example, many Japanese and Chinese avoid talking about death because they believe that doing so may bring misfortune [11,12,13]

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