Who Prefers Death to Life in Composite Time Trade-off Interviews, and Why? A Mixed-Methods Study among Asians in Singapore

OBJECTIVES: The EuroQol Valuation Technology (EQ-VT) uses composite time trade-off (cTTO) with a 10-year lead-time to value health states worse-than-dead (WTD) ranging between - 1 and 0 (dead). While WTD responses are common in EQ-5D-5L studies, their drivers remain understudied in Asia. This mixed-methods study explored socio-demographic factors and reasoning behind WTD preferences in Singapore.

METHODS: We recruited 500 adult Singaporeans using quota sampling. Each participant completed 20 cTTO tasks through computer-assisted interviews, followed by open- and closed-ended questions. Two-part regression models assessed both the likelihood and the extent of WTD ratings, and qualitative content analysis evaluated participants' reasoning for their health state valuations.

RESULTS: Of the 500 participants (mean age 48.1 years; 52.6% had tertiary education), 76.8% identified as Chinese. Overall, 33.0% assigned WTD values, and 16.1% assigned '- 1' values. Age, education, marital status, interviewer and caregiving experience were associated with WTD ratings, though none remained significant in the multivariable analysis. Similar factors were linked to '- 1' values, with middle age being the only factor that remained significant in the multivariable analysis. Qualitative data showed that middle-aged participants often cited worries about imposing physical, mental, or financial burdens on their families.

CONCLUSIONS: Preferences for immediate death over living in poor health are common in Singapore, particularly among middle-aged respondents. Concerns about burdening family members appear to drive these preferences, reflecting broader cultural values. These insights may clarify the high frequency of '-1' values in EQ-5D valuation studies across Asia.