JOURNAL OF PALLIATIVE MEDICINE
Volume 10, Number 6, 2007
© Mary Ann Liebert, Inc.
Racial Differences in the Willingness to Use Hospice Services
ROBERT L. LUDKE, Ph.D.1and DOUGLAS R. SMUCKER, M.D., M.P.H.2
Objective: This study assesses whether racial differences exist in the willingness to use hospice ser-
vices in the future among black and white adults and potential factors that may contribute to such
Methods: Data were collected from the City of Cincinnati component of the Greater Cincinnati
Survey. A total of 510 random-digit-dialed telephone interviews were completed, with 473 adults in-
cluded in the analyses (220 blacks, 253 whites).
Results: Relative to whites, blacks were significantly less likely to consider using hospice if they
were near the end of life because of a terminal illness and less likely to do so even if their doctor
strongly recommended its use. This reluctance was related to their prior exposure to hospice as well
as their trust in their doctor to make the right end-of-life care decisions. Like whites, blacks who
had a positive prior exposure to hospice were more willing to consider using hospice than those who
have not been exposed to hospice, but only for those blacks who trust their doctor. For blacks who
do not trust their doctor, those with prior hospice exposure, regardless of their level of satisfaction,
were less willing to consider hospice than those without prior exposure.
Conclusions: Efforts to increase utilization of hospice services among blacks requires greater in-
sight into the experiences that they have with hospice services for their family members and friends
as well as their level of trust in their physician’s decision making about end-of-life care.
tance.1–3In particular, minority Americans are at
greatest risk for underutilization of hospice care.4,5
Racial and ethnic minorities represent only 5%–7% of
the hospice patient population.6Blacks have 40%
lower hospice use than whites,7,8although recent ev-
idence suggests that this gap may be closing.9Some
researchers argue that these differences result from
hard-to-measure socioeconomic factors, variations in
insurance coverage, job or familial obligations, lim-
ited geographical access to hospice care, less at-home
caregiver support, and lack of a primary care physi-
OSPICE REMAINS an underused resource for dying
patients despite its rapid growth and accep-
cian for hospice referral.4,8,10–13Others suggest that
economic, educational, and access-to-care differentials
between blacks and whites are not the primary expla-
nation.8There may be other important causes, such as
differential care preferences, differences in knowledge
to seek out or accept hospice care,6overt racial bias
at the individual or institutional level,14differential
treatment based on racial/ethnic stereotyping or dis-
crimination,14and language or other cultural barriers.8
Mistrust, also hypothesized to be a prominent barrier
for blacks,6,15may flourish most within a setting where
the cultural/racial background of health care workers
is not the same as the patient’s.16
Given its philosophy, and the makeup of its work-
force, hospice may be a foreboding place for blacks.15
1Institute for the Study of Health, 2Department of Family Medicine, University of Cincinnati Academic Health Center,
Although a majority of all Americans would prefer to
die at home,17,1862% of blacks would prefer to die in
the hospital.19Blacks reportedly have lower interest in
and knowledge of hospice care than whites.6,11,20
There may also be a lack of agreement with the hos-
pice philosophy among blacks.15Blacks see longevity
as an intrinsic good,21are reluctant to discuss advance
directives,22prefer curative care,23and hesitate to wel-
come strangers from hospice into their homes.24
While there are a number of proposed explanations
for the differences between blacks and whites in hos-
pice utilization, there is a lack of empirical evidence
on which to base educational and outreach efforts to
reduce the differences. There are no studies that ex-
amine differences in attitudes about considering hos-
pice care in the future among a population-based sam-
ple of community residents who do not have a
life-threatening illness. This study assesses whether
racial differences exist in the willingness to use hos-
pice services in the future among black and white res-
idents of a large Midwestern city, and potential fac-
tors that may contribute to such differences.
Data were collected in spring 2005 from questions
added to the City of Cincinnati component of the
Greater Cincinnati Survey. This random digit dialed
telephone survey of about 1500 adults (age 18? years)
in the four Ohio, one Indiana, and three Kentucky
counties surrounding Cincinnati is conducted semian-
nually by the University of Cincinnati Institute for Pol-
icy Research. Of the approximate 253,000 adult resi-
dents of Cincinnati, 57.5% are white, 37.6% are black
or African American, and 5.0% are of other racial
Forty-one interviewers (19 black, 21 white, 1 Asian)
conducted the survey. Each interviewer was trained by
a full-time Field Director in survey research methods,
computer/CATI interviewing and navigation, and the
specific nature of this project. Interviewers read a stan-
dardized interview protocol to respondents using the
WinCati Computer Aided Telephone Interviewing sys-
tem. Respondent questions about individual survey
items were first addressed by the interviewers using a
prepared script and, if necessary, referred to supervi-
sors. The questions were pretested 1 to 2 weeks prior
to the conduct of the survey using a minimum of 20
interviews. None of the survey questions used in this
study was modified based on these pretest interviews.
There were no additional validity/reliability checks of
the survey questions. The data were weighted to be
representative of the demographic profile of the city.
The survey questions used to measure the follow-
ing constructs are presented in Table 1. Given the ab-
sence of previous research related to willingness to use
hospice services, the questions were generated by the
authors except where noted in Table 1.
Willingness to use hospice. Willingness to use hos-
pice services was assessed by two questions (Ques-
tions 1 and 2, Table 1). Answers to Question 1 were
operationally defined as a dichotomous variable: yes
(definitely yes, probably yes) and no (definitely not,
probably not, don’t know). Respondents who provided
a response other than yes to Question 1 were then
asked Question 2. Answers to these two questions were
combined into a trichotomous variable to describe
willingness to use hospice in the future: yes (definitely
yes/probably yes from Question 1), yes if doctor rec-
ommended (definitely yes/probably yes from Question
2), and no/don’t know (definitely not/probably
not/don’t know from Question 2).
Previous hospice exposure. Previous exposure to
hospice care was determined by a single item (Ques-
tion 3, Table 1) categorized into a yes, no/don’t know
Satisfaction with previous hospice care. Satisfaction
with previous exposure to hospice care was measured
by a single item (Question 4, Table 1). Responses were
categorized into a dichotomous measure: yes (very sat-
isfied, somewhat satisfied) and no (neither satisfied
nor dissatisfied, somewhat dissatisfied, very dissatis-
fied, don’t know).
Previous hospice experience. Responses to Ques-
tions 3 and 4 were combined to create a trichotomous
summary variable to describe previous hospice expe-
rience: no prior exposure (no/don’t know from Ques-
tion 3), prior exposure—not satisfied (no/don’t know
from Question 4), and prior exposure—satisfied (yes
from Question 4).
Attitude toward end-of-life care.Responses to Ques-
tion 5 (Table 1) were categorized into an agree/not
agree dichotomous variable, with don’t know re-
sponses included in the not agree category.
LUDKE AND SMUCKER 1330
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Address reprint requests to:
Robert L. Ludke, Ph.D.
Institute for the Study of Health
University of Cincinnati Academic Health Center
P.O. Box 670840
Cincinnati, OH 45267-0840
WILLINGNESS TO USE HOSPICE1337