Examining the Intersectionality of Race, Ethnicity, and Gender in Advance Care Planning

Background/Purpose: Racial and ethnic disparities in advance care planning (ACP) are well-documented; however, limited research examines gender’s moderating effects despite its significant role in ACP practices. This secondary analysis of a nationally representative sample from the Health and Retirement Study (HRS) examines the interaction effect of gender on race/ethnicity in predicting ACP completion.

Literature has documented racial and ethnic disparities in ACP. Recent research also highlights the influence of gender, a social identity linked to discrimination, on ACP. Using an intersectionality lens, this study examines the interaction between race/ethnicity and gender—both social identities contributing to discrimination in ACP. This approach is particularly relevant for racial and ethnic minorities, where gender effects may be more pronounced. The findings provide evidence for future research to incorporate intersectional analyses with other social identities, such as disability and sexuality.

Methods: Data and samples: To investigate whether the effects of race and ethnicity on the completion of ACP, including living wills and durable power of attorney for health care (DPAHC), are moderated by gender, a secondary analysis using data from the HRS spanning 2006–2016. The sample included 5,312 deceased individuals aged 65 and older.

Measures: Race and ethnicity were categorized into three groups: non-Hispanic White, non-Hispanic Black, and Hispanic. The dependent variables comprised the completion of living wills or DPAHC. Gender was assessed by the participant’s sex, with response options of male or female. Guided by Andersen s Behavioral Model (BM) and previous research, 11 covariates were included: age, depression, religion, functional limitations, geriatric syndromes, education, marital status, income, birthplace, chronic diseases, and cognition.

Results: A hieratical logistic regression showed that race/ethnicity significantly predicted the completion of ACP. As compared to non-Hispanic Whites, Non-Hispanic Blacks were least likely, followed by Hispanics, to have living wills or DPAHC.

A logistic regression analysis showed no significant interaction effect between race/ethnicity and gender on the completion of living wills, but a significant interaction effect was observed between race/ethnicity and gender on the completion of a DPAHC (p = .006 for the interaction between gender and Hispanic ethnicity). Specifically, the interaction was examined by testing the conditional effects of race/ethnicity across gender categories. Among non-Hispanic Black and Hispanic participants, gender did not have a significant effect on the presence of a DPAHC (Ps >0.05). However, the odds of completing a DPAHC were 1.41 times higher for females than for males among non-Hispanic White participants (p < .05).

Conclusions and Implications: This study highlights the role of gender in shaping racial and ethnic disparities in ACP, which may reflect differences in healthcare engagement. Women are more likely than men to seek preventive care and may experience greater gender and racial concordance with providers, influencing their willingness to complete ACP. Social work interventions should consider gender dynamics within communities. Future research should examine how other identities linked to discrimination contribute to ACP disparities, in order to inform more equitable health care policies and practices.