Exploring associations between older adults’ demographic characteristics and their perceptions of self‐care actions for communicating with healthcare professionals in southern United States

Abstract Aims This study examined associations between older adults’ demographic factors and their perceived importance of, desire to and ability to perform seven self‐care behaviours for communicating with healthcare professionals. Design This cross‐sectional survey study analysed subset data of 123 older adults 65 years and older, living in southern United States. Methods The Patient Action Inventory for Self‐Care (57 items, grouped into 11 categories) was used to collect self‐reported self‐care data. Demographic characteristics were also collected. Descriptive statistics and logistic regression analyses were used to tests for relationships between the variables relevant to the research objective. Results Regression findings showed that separated older adults felt less able to share ideas about their healthcare experiences compared to married older adults. Male older adults reported less desire to list issues to discuss and less desire to share ideas about their care experience with their healthcare professionals compared to their female counterparts.

to discuss with their care providers, were less likely to have used emergency room services in the past 3 months. Additionally, adults who indicated that they were able to share their physical symptoms with their healthcare professionals were also less likely to have used emergency room services in the past three months (Tzeng, Pierson, et al., 2019). Similarly, a recent qualitative study exploring suggestions from older adults to promote patient-engaged health delivery in western Canada revealed older adults' desire to have a conducive clinical environment that fosters effective communication with their healthcare providers . As far as we know, there are no current studies that investigate the influences and contributions of patient demographic characteristics to these perceived perceptions of the self-care actions related to communicating with their healthcare professionals in the United Stated and other countries.

| Objectives and design of this study
In order to develop patient-centred health policies and improve health practices for the older adult population in general, it will require an understanding of older adults' perceptions of self-care actions that are needed for them to communicate with healthcare professionals, as well as the associations between their perceptions and demographic characteristics. Therefore, the purpose of this study was to explore the relationships between community-dwelling older adults' demographic characteristics and their perceptions of self-care actions for communicating with healthcare professionals in the southern parts of the United States. The main research question of this study is Are older adults' demographic characteristics associated with their perceived importance levels of self-care actions for communicating with healthcare professionals, as well as their desire and ability to perform these actions?
This cross-sectional survey study employed the use of a secondary data analysis to explore and understand the relationship of five older adults' demographic characteristics with their self-reported importance levels of seven patient engagement self-care actions for communicating with healthcare professionals, along with their desire and ability to perform these actions. The five patient demographic characteristics selected in this study were residence in an urban or rural site, gender, age group, marital status and education level. This study used a study design approach similar to a recent study conducted by Tzeng et al. (2018), with a different self-care focus area. The secondary data used in this study are part of a crosssectional survey project (Tzeng, & Pierson, 2017a). The Center for Advancing Health's Engagement Behavior Framework (CFAH, 2010(CFAH, , 2014a(CFAH, , 2014b was used as a theoretical framework to guide the larger study that these data came from. The Engagement Behavior Framework (CFAH, 2010(CFAH, , 2014a(CFAH, , 2014b was meant to help adults understand what they need to do to benefit from the health services available to them in the context of the US healthcare system.
In other words, patient engagement is conceptualized, based on the definition used by the Center for Advancing Health (CFAH, 2010(CFAH, , 2014a(CFAH, , 2014b, as the behaviours adults need to equip to obtain the greatest benefit from the healthcare services available to them in their community. In this study, we examined seven patient engagement behaviours required to effectively communicate with healthcare professionals, as defined in previous studies (CFAH, 2014a(CFAH, , 2014bTzeng, & Pierson, 2017a, 2017bTzeng, Pierson, et al., 2019). Patients' self-reported perception of each of the seven actions was measured using yes/no questions for each action's importance, desirability to perform and patient ability to perform. The seven self-care actions explored in this study bordered around the following thematic areas: (a) itemizing questions and issues to discuss with a healthcare personnel before or during a healthcare appointment, (b) having a personalized list of medications and taking them to one's healthcare appointments,  (Tzeng, & Pierson, 2017a).
As for the relevance of this present study to international readers, it is commonly perceived that cultural considerations could hinder access and use of healthcare resources, due to such as communication barriers (e.g., linguistic or health literacy related), historical mistrust between patients and healthcare providers, racism and discrimination (e.g., stigma related to people with advancing age) (National Academies of Sciences, Engineering, & Medicine, 2019).
These communication barriers are not unique to the United States.
These barriers could happen in any community in our global village and vary from community to community (e.g., because of different cultural beliefs and local geographical characteristics). To address communication barriers, it is critical that healthcare systems and healthcare providers recognize and respect that patients' viewpoints about health and well-being could differ (e.g., their desire to perform certain self-care actions to navigate through the healthcare systems) (National Academies of Sciences, Engineering, & Medicine, 2019).

| Literature review
Two recent studies concluded that it is essential to establish a checklist of desired self-care behaviours to involve adults in their own health and health care, such as those related to communicating effectively with healthcare professionals (Tzeng, & Pierson, 2017a, 2017b. At each patient-clinician encounter, patients often anticipate open, accommodating and unbiased medical communication from healthcare professionals, because patients want their providers to attend to their health issues (Cené et al., 2009). However, this has not been the case based on studies carried out to explore this idea.
For example, in studies conducted by Sudore et al. (2009) reached the conclusion that patients perceive instructions from physicians to be ambiguous and not clearly communicated or easily understood.
These findings are in agreement with many other studies (Nguyen, Hong, & Prose, 2013;Roscoe, Tullis, Reich, & McCaffrey, 2013;Scholl, Zill, Härter, & Dirmaier, 2014;Tariman, Berry, Cochrane, Doorenbos, & Schepp, 2012 Siminoff, Graham, and Gordon (2006) explored the relationships between patient communicative engagements with healthcare professionals and patients' demographic characteristics. They found that patients who were older, more educated and more affluent were more prone to participate in more communicative engagements than their younger, less educated or less affluent counterparts (Siminoff et al., 2006). A few other studies (Beverly et al., 2012(Beverly et al., , 2011Ritholz, Beverly, Brooks, Abrahamson, & Weinger, 2014), exploring factors that hinder open communication between patients and healthcare professionals, cited that these precedents may to be due to fear of judgement, guilt or shame. These findings further emphasize the need to develop optimum and desirable approaches that would facilitate and promote active interaction between patients and their healthcare professionals. This is imperative as patients who lack the desirability and ability to effectively communicate with their healthcare professionals may limit the quality of the healthcare received and their motivation as patients to further pursue healthcare services (Hashim, 2017;Johnson, Saha, Arbelaez, Beach, & Cooper, 2004;Ozaras & Abaan, 2016;Saha, Arbelaez, & Cooper, 2003;Siminoff et al., 2006;Tzeng, Okpalauwaekwe, et al., 2019;Tzeng, & Pierson, 2017a;Zachariae et al., 2003).

| Study design
A secondary data analysis was conducted using the data from a cross-sectional survey study on community-dwelling adults living in the southern United States, 2015-2016 (Tzeng et al., 2018;Tzeng, & Pierson, 2017a). This survey study obtained ethical approvals from both the Tennessee Technological University's Institutional Review Board and the University of Saskatchewan's Ethics Committee.
Participants provided written consent for their data to be used in the study. The study was carried out in accordance with the principles of the Declaration of Helsinki.
This study was conducted in a region with a total of 14 counties; one of the countries is categorized as an urban area and rest of them are rural. This region is located in the middle part of a southern state (2017 state population: 6,715,984). As for the racial composition, in 2013, 79.1% are White, and 17% are Black (Wikipedia, 2019). This region is about an hour by car via highways from the state capital. An area agency on ageing and disability was located in the urban county within this region to offer various services for residents 60 years or older and the ones with a disability. Services include, but not limited to, senior centres, home-delivered meals, congregate meals in social settings, family caregiver support, homemaker service, personal care, adult day care, public guardianship, advocates on behalf of residents of long-term care facilities, legal assistance, educating older adults Medicare and Medicaid beneficiaries on how to reduce and report health insurance fraud, transportation and supplemental nutrition assistance programme (Upper Cumberland Development District, 2019).

| Conceptual framework
This study was designed based on the Engagement Behavior

| Study subjects
Convenience sampling was used to recruit community-dwelling adult subjects 18 years and older. Participation was voluntary. A total of 250 subjects (response rate 82%) participated in the survey project. This study only includes responses from participants aged 65 years and older (N = 123). A detailed description of the methodology employed in the studies has been published (Tzeng et al., 2018;Tzeng & Pierson, 2017a).
To calculate the required sample size, the guideline developed by Peduzzi, Concato, Kemper, Holford, and Feinstein (1996)

| Data collection instruments
The self-administered survey of community-dwelling adults included two parts. The first was data collected in the Patient Action Inventory for Self-Care, an 11-category measurement inventory with a total of 57 items across 11 categories. The second part included questions to collect demographic characteristics. The full survey required about 40 min to complete. (Tzeng et al., 2018;Tzeng & Pierson, 2017a).
For the Patient Action Inventory for Self-Care questionnaire, participants were asked to indicate yes or no for each action statement from three perspectives as follows: (a) Is this important to you? (b) Do you want to do this? and (c) Are you able to do this? (Tzeng et al., 2018;Tzeng & Pierson, 2017a). Participants' answers to the seven self-care behaviours in one of the 11 categories (Category 2: communicating with healthcare professionals, tool action items 5-11), were analysed, which were (1) making a list of questions and issues to discuss at your appointment (tool action 5); (2) listing your medications and taking your list to appointments (tool action 6); (3) being ready to talk about your medications and what they do (tool action 7); (4) sharing all your physical symptoms and history with your healthcare providers (tool action 8); (5) sharing all your mental symptoms and history with your healthcare providers (tool action 9); (6) asking questions of your provider when needed (tool action 10); (7) sharing your ideas about the care experience (tool action 11) (Tzeng & Pierson, 2017a).

| Data analysis
We used IBM SPSS 23.0 statistical software for analyses (IBM Corp., 2015). Statistics were calculated without adjusting for missing values; in other words, data from completed or partially completed surveys were included in the analysis. Descriptive analyses (i.e., frequency counts and percentages) were used to describe the sample. Univariate logistic regression was performed to evaluate the contribution of individual demographic characteristics. Multiple logistic regression (method = enter) was completed to evaluate the influence of the five identified demographic characteristics on the chance that older adults would report that they perceived each of included seven self-care actions as being imperative, wanted and capable to perform by participants (yes = 1, no = 0). The alpha value was set at 0.05 for two-tailed tests. Table 1 presented the descriptive statistics of the demographic characteristics and the included self-care actions. The majority of the older adults lived in a rural area (61.8%; N = 76), were female (73.3%; N = 90), hold at least a high school diploma (66.7%; N = 82) and were White (90.2%; N = 111). Sixty (48.8%) of them were at least 65 and younger than 75 years of age. Relationship status was fairly equally divided between married (39%; N = 48) and single (9.9%; N = 49).

| Demographic characteristics
Four (3.3%) of them did not have health insurance.

| Univariate logistic regression findings
Among the included patient demographic characteristics tested, univariate logistic regression analysis showed statistical significance only for marital status and the ability level to perform self-care communication action item 7 (i.e., sharing ideas about care experience) (p-value = 0.042; OR 0.069; 95% CI = 0.005-0.913) (see Table 2). This model explained between 5.4% (Cox & Snell R square)-14.3% (Nagelkerke R square) of the variance and correctly classified 93.7% of cases. Only separated marital status was statistically significant.
The odds ratio of 0.069 for separated marital status (compared to married) was less than 1, indicating that the odds of being able to perform communication action item 7 is (1 − 0.069) × 100% = 93.1% lower for a separated person compared to those who were married.

| Multiple logistic regression findings
Three multiple logistic regression models including all five demographic characteristics and with at least one statistically significant regression coefficient value are summarized in Table 3  for a separated person compared to a person who is married.

| D ISCUSS I ON
As shown in the results, among the seven self-care behaviours related to communicating with healthcare professionals, communication action items 1 and 7 (i.e., making a list of healthcare issues and sharing ideas about care, respectively) showed significant relationships with gender and marital status. These two findings are consistent and imply that separated older adults are not able to share their ideas about the care experience with their healthcare professionals compared with their married counterparts. In the same vein, male older adults were showed to have less desire to perform both self-care communication action items 1 and 7 (making a list of healthcare issues and sharing ideas about care, respectively) than female older adults. This implies that male older adults had less desire to list their healthcare concerns and also less desire to share their ideas about their care experience with their healthcare professionals, compared to their female counterparts. These study's findings were not in agreement with the findings of Siminoff et al. (2006) who reported that older, more educated and more affluent patients have greater communicative engagement with physicians than their younger, less educated or less affluent counterparts. The findings of the present study could be interpreted to add to our understanding of communication disparities in variable contexts.
Furthermore, our study results showed that male older adult patients were less likely to communicate effectively with their healthcare providers, compared to their female counterparts. This finding is supported by several studies in the social science field, which asserts that females are expressive in verbal and non-verbal communication techniques than males (Hall, 1984;Hall & Roter, 2002;Kiss, 2004;Zaharias, Piterman, & Liddell, 2004). While we acknowledge that there might be nuances, such as patient-healthcare professional gender dyads (e.g., male or female patients being more comfortable to communicate based on gender differences with the physician or nurse) that could have modified our results (Jefferson, Bloor, Birks, Hewitt, & Bland, 2013;Mast & Kadji, 2018;Shin et al., 2015). We interpret our results with caution having these in mind. Further research on these subtleties could further elucidate on how these could confound or interact with our study results.
In this study, our results emphasize the need for patient-centred care in health practice. Healthcare professionals (i.e., nurses, nursing practitioners and other professional healthcare providers) should be prepared to support older adults, regardless of their gender or other demographic characteristics, to find their voice in holding effective dialogue with their healthcare professionals. This is because professional nurses are entrusted with the responsibility to provide holistic care to patients as they deal with them more closely (Ozaras & Abaan, 2016 to the free or low-cost services or programmes provided by an area agency on ageing and disability with a goal to improve older adults' confidence or provide support in communicating with healthcare professionals could be beneficial. This may be a promising avenue for research following the findings set by Siminoff et al. (2006), who found that White patients were reported to have more expressive communication with their healthcare providers than their non-White counterparts, or Cené et al. (2009), who found that significant differences in quality patient-physician communication between Black and non-Black patients (e.g., Blacks had shorter physician visit and less communication than Whites).

| CON CLUS IONS
This study concluded that among the seven self-care actions for communicating with healthcare professionals, two self-care actionsmaking a list of questions and issues to discuss at your appointment (communication action item 1) and sharing your ideas about the care experience (communication action item 7)-were associated with gender and marital status among community-dwelling older adults.
Healthcare professionals should intentionally observe and assess patients who may be separated or male older adults in their ability to communicate effectively and expressly with their healthcare providers, especially with older adults who are more susceptible to visit the emergency rooms or clinic. This has been supported by our study to be an essential requirement for patient-centred care and patient engagement among older adults.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.