Socioeconomic disadvantage and stage-specific psychosocial pathways to advance care planning engagement in Taiwan

Background Advance care planning (ACP) is a staged process. Taiwan’s Patient Right to Autonomy Act (PAA) requires a fee-based consultation before a legally valid advance directive (AD) can be completed, separating consultation entry from documentation. Objectives To examine whether socioeconomic disadvantage is associated with willingness at each stage, and whether health literacy, perceived unfairness, generalized trust and provider trust relate to the stages differently. Design Secondary analysis of cross-sectional survey data. Methods Data were drawn from 1,384 adults in the 2021–2022 Taiwan Social Change Survey. Generalized structural equation models with ordinal probit links assessed willingness to pay for and enter the PAA-mandated consultation and to complete an AD. Results Low income was associated with lower consultation willingness (b = −0.023, p = .011) but not AD willingness (b = −0.016, p = .088), and with poorer standing on all four psychosocial variables. Correlates differed by stage: consultation with perceived unfairness (b = −0.114, p = .003) and generalized trust (b = 0.094, p = .010); AD willingness with health literacy (b = 0.083, p < .001) and PAA awareness (b = 0.327, p < .001). Adjusting for education attenuated both income coefficients to non-significance (consultation b = −0.015, p = .107; AD b = −0.008, p = .447), while education was significant at both stages. Tested jointly, income and education were associated with both outcomes (consultation χ 2 (2) = 13.71, p = .001; AD χ 2 (2) = 10.71, p = .005), and the stage-specific pattern held. Conclusion Socioeconomic disadvantage, indexed jointly by income and education, was associated with willingness at both ACP stages, but the relevant psychosocial correlates differed. Because the consultation item specifies an out-of-pocket fee, this reflects ability to pay as well as willingness to engage. Equity-oriented implementation should combine affordable, trustworthy consultation with literacy-sensitive support for documentation.