Examining Baseline Readiness and Contextual Moderation In Advance Care Planning (ACP) Knowledge and Willingness Among Korean Immigrants

Background and Significance: Advance care planning (ACP) is associated with greater use of palliative and hospice care, fewer aggressive treatments, and improved quality of life, as well as reduced decisional burden among family caregivers. Despite these benefits, racial and ethnic minorities, including Asian Americans, show lower ACP engagement, particularly Korean immigrants due to lower acculturation and limited healthcare access. This study examined changes in ACP knowledge and willingness among Korean immigrants in Alabama following a community-based intervention and assessed whether post-intervention outcomes varied by sociodemographic and contextual characteristics, accounting for baseline levels.

Methods: Data were drawn from a one-group pre-post study of Korean immigrant adults (N = 123) in Alabama, recruited using purposive and convenience sampling and participating in a culturally tailored, community-based ACP intervention (March–December 2025). The intervention was informed by prior ACP studies and refined through a community advisory board to ensure cultural relevance. Participants completed surveys immediately before and after the intervention. Outcomes included ACP knowledge (Cronbach’s α=.502–.571), Palliative Care Knowledge Scale (PaCKS; α=.555–.690), and single-item measures of willingness to complete an advance directive and engage in health care conversations (1=Not at all likely to 4=Very likely). Paired-samples t-tests examined pre-post changes. ANCOVA models assessed group differences in post-intervention outcomes by sociodemographic characteristics (e.g., age, length of U.S. residence, marital status), controlling for baseline scores. When the homogeneity of regression slopes assumption was violated, moderated ANCOVA models were estimated.

Results: Participants demonstrated significant improvements across all outcomes from pre- to post-intervention (p-values <.05). After adjusting for baseline levels, no significant differences in post-intervention outcomes were observed across age, sex, education, income, or religious affiliation. Across all models, baseline scores were significant predictors of post-intervention outcomes, indicating that initial levels of knowledge and willingness remained significantly associated with post-intervention outcomes. However, moderation analyses revealed that the association between baseline and post-intervention PaCKS knowledge was significantly weaker among participants with shorter residence in the U.S. compared to long-term residents (p=.004, partial η²=.089). A similar pattern was observed for willingness to engage in health care conversations, where baseline willingness was less predictive of post-intervention willingness among those with 5–15 years of residence than those with more than 15 years (p=.038, partial η²=.054). In addition, marital status significantly moderated the relationship between baseline and post-intervention PaCKS knowledge, with weaker associations observed among married or partnered individuals (p=.012, partial η²=.052).

Conclusion: This culturally tailored ACP intervention was associated with improvements in ACP knowledge and willingness to engage in planning among Korean immigrants. Consistent with prior research, baseline levels of knowledge and willingness were significant predictors of post-intervention outcomes, underscoring the importance of early education. Moderation findings further indicated that the association between baseline and post-intervention outcomes was weaker among newer immigrants and married individuals, suggesting that these groups may benefit from the intervention regardless of initial readiness. Overall, community-informed, culturally relevant approaches may play an essential role in increasing ACP engagement among Korean immigrant populations.