Date of Award


Document Type

Open Access Dissertation

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Kathrin Boerner

Second Advisor

Kyungmin Kim

Third Advisor

Sara Moorman


Research has focused on various individual characteristics associated with advance care planning (ACP), but little is known about how the environment context is associated with ACP. This study examined the role of environmental characteristics in ACP by addressing three key aims: 1) examine the independent effects of environmental factors on ACP, 2) assess the moderating effects of environmental factors on the associations between ACP and individual household income and educational attainment, and 3) conduct a longitudinal examination of ACP and environmental characteristics. I combined individual ACP information from the 2004 and 2011 waves of the Wisconsin Longitudinal Study with county level characteristics from publicly available datasets (i.e., Dartmouth Atlas, US Census Bureau, and the Area Health Resource File). Multilevel models showed that several environmental factors were associated with ACP, including county level sociodemographic (e.g., rurality, age composition, prevalence of one-person households) and healthcare-related characteristics (e.g., number of hospice agencies, Medicare reimbursement rates). Environmental factors also revealed moderating effects in the associations between ACP and individual household income and educational attainment. Moreover, results indicated longitudinal effects of environmental characteristics in obtaining ACP status over time. Findings from this study suggest that the environmental context of an individual’s residence can impact their engagement in ACP, even after controlling for their individual characteristics. Evidence from this study may be used to target areas for, and guide the design of, effective intervention strategies to help increase ACP at an environmental level.

Included in

Gerontology Commons