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Death Attitudes as Possible Predictors of Death Preparedness across Lifespan among Nonclinical Populations in Nairobi County, Kenya
Address for correspondence: Dr. Stephen Asatsa, Department of Psychology, The Catholic University of Eastern Africa, Nairobi, Kenya. E-mail: steveasatsa@gmail.com
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Received: ,
Accepted: ,
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This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Context:
Death is an important part of lifespan development, yet it remains trivialized or feared across many cultures. The perpetuation of death as a taboo subject continues to negatively affect the society. Death anxiety inhibits death preparedness which could affect the quality of dying. The pool of unclaimed assets held by different organizations continues to increase, intestate deaths remain high, and post death conflicts continue to affect many families.
Aims:
This study intended to examine death attitudes as possible predictors of death preparedness and explore the rationale for various death attitudes across lifespan in Nairobi, Kenya.
Methods:
The study adopted the mixed-methods explanatory sequential research design combining cross-sectional and phenomenological designs. The study targeted young adults, middle-aged adults, and seniors with a sample of 335 participants selected using multistage, stratified, and extreme case sampling designs. Data were collected using the Death Attitude Profile-Revised and interview guides.
Analysis:
Data were analyzed using univariate and thematic analyses.
Results:
The findings indicated that negative death attitudes declined with increase in age, whereas positive death attitudes increased with increase in age. Some of the reasons for negative death attitudes included threatening dying process, unfulfilled life goals, fear of hell, unresolved past deaths, and families with young children among others. The reasons for positive death attitude included reuniting with deceased loved ones and peers, meeting the creator, and end to a prolonged miserable life and fulfilled past life.
Conclusion:
This study implies that mental health practitioners need to target younger adults with death education programs to promote death preparedness and quality dying. For the older adults, addressing life regrets, family conflicts, and past unresolved deaths would significantly improve the quality of dying.
Keywords
Death acceptance
death attitudes
death preparedness
nonclinical population
INTRODUCTION
Background of the study
Death, just like birth, is a stage in human growth and development. It is an inevitable and final part of one's lifespan. However, many people across the world continue to perceive death negatively. In an attempt to minimize intense fear toward death, many cultures employ the use of euphemism when talking about death. Nyakoe et al.[1] and Ondimu[2] assert that use of euphemism is a proof for lack of death acceptance, which is a soft form of death negation. Afful[3] links denial and avoidance of death to the use of statements such as “passing away” instead of “dying,” “laid to rest” instead of “buried,” “remains” instead of “corpse,” “life-threatened patients” instead of “dying patients,” and “fallen soldiers” instead of “dead soldiers” among others.
The treatment of death as a taboo subject is evident among scholars and researchers too; for quite a long time, researchers have had little focus on death. It was not until late 1959 that scientific research on death began.[4] The work was pioneered by Herman Feifel and Elizabeth Kubbler-Ross, which formed the basis for modern research on death-related issues. Since then, various studies have been carried out by other scholars, which has helped to shape the current literature on death in various Western countries. An analysis by Wittkowski et al.[5] indicates that major journals on death, in the last 20 years, have been published in North America, Europe, and Australia. Majority of studies that inform current literature on death have been conducted outside Africa. The hesitant approach to death studies by most researchers is also evident by the limited number of standardized tools developed in the field of death and dying. Currently, the Death Attitude Profile-Revised (DAP-R) and the Multidimensional Orientation Toward Dying and Death Inventory-F are the most comprehensive standardized questionnaires designed to measure various aspects of death.[6] The tools were developed in 1994 and 2001, respectively. The continued consensus among thanatologists that these are the most comprehensive tools in death studies despite their age is a clear indication for lack of interest in death studies by many researchers.
Quality dying is a concept that is gradually gaining momentum globally. People are slowly becoming aware that death is inseparable with life and ought to be accepted rather avoided. Meridith et al.[7] view a good death in terms of comfort, control, and acceptance for the dying person. They argue that quality dying is enhanced by pain reduction, comfort provision, and facilitation of death acceptance for the dying person. Many scholars agree that quality dying involves awareness and acceptance of one's past life and impending death followed by end-of-life planning.[8] In the Western world, quality dying is a fully developed concept that is fully entrenched in the mental health sector. The World Palliative Care Association[9] asserts that palliative care is a human right that should be accorded to all with the aim of ensuring dignity during the dying process.
In Africa, hospice movement and palliative care is still a new concept. However, several countries have made attempts to establish these centers in order to meet the needs of dying patients. The few available palliative care centers in Africa are established to meet the needs of patients diagnosed with terminal illnesses such as cancer and AIDS.[10] It is also evident that the focus of palliative care services to the terminally ill patients addresses a small percentage of the population, leaving out majority of the people dying from causes other than terminal illnesses.
Lack of death preparedness is prevalent among Kenyans just like the rest of the world. The Unclaimed Financial Assets Authority (UFAA) estimated the value of unclaimed assets in Kenya by 2015 to be 200 billion shillings, most of which belonged to people who died before disclosing their wealth to their families. The authority also attributes this huge amount of unclaimed assets to intestate deaths, which are rampant in Kenya.[11] In most cases, intestate death often translates into bitter succession court cases among the surviving family members, leading to painful postdeath family relationships. This trend is an indicator for the need to prepare for death by majority of Kenyans as a way of boosting the mental health of dying persons.
The mental health sector in Kenya lacks formal policies on death preparation. Most of the resources in the Ministry of Health are directed to death prevention. Palliative care is the only death preparation program being undertaken by the Ministry of Health but remains skewed toward terminally ill patients, leaving out a very large percentage of the Kenyan population. According to the Ministry of Health,[12] there are 32 hospices and palliative care centers in Kenya with a total population of over 45 million people. The Kenya Network of Cancer Organizations[13] noted that with the increasing cancer load in the country, the few available palliative care centers are dedicated to the management of cancer patients. Death remains a taboo subject in Kenya where continued overuse of euphemism in death language is rampant as observed by Ondimu.[2] The Funeral Services Association of Kenya has added its voice to this public outcry where it claims that its members face stigma and trauma for doing death-related jobs.[14] The organization observes that its members are branded as “abnormal” by the general public, making it difficult for them to fit in the society, and engage in social activities such as dating. The association further observes that negative public perception of death has created shortage of workers in the industry, where mortician jobs are advertised and no one applies. This study explored death attitudes across lifespan in Nairobi and the rationale that shapes these attitudes. The aim was to avail literature that would inform theory and improve end-of-life planning in order to promote quality dying.
METHODS
The study was carried out in Nairobi County, Kenya's capital city. The county is divided into various administrative units including 9 subcounties, 27 divisions, 64 locations, and 135 sublocations. Being the capital city of Kenya, the area was assumed to be a representation of the Kenyan cultures, which makes the study results generalizable to other counties in Kenya.
This study adopted the explanatory sequential mixed-method research design. This approach was chosen for its ability to use quantitative data to test hypothesis and follow-up with qualitative data to explain the results.[15] The study began with quantitative data collection in the first phase followed by the qualitative data collection in the second phase. Qualitative phenomenology was required to provide in-depth explanation of patterns that emerge out of the cross-sectional survey such as group differences and extreme scores.[16] This study targeted adults living in Nairobi County aged at least 20 years of age across various religions. The religions targeted ranged from Protestants, Roman Catholics, Muslims, Hindus, traditionalists, and atheists.
Both probability and nonprobability sampling techniques were used in selecting the participants from a sample of 340, of which 20 were selected to give qualitative data. Multistage sampling technique was used to enlist participants for the study. In the first stage, 30% of the subcounties in Nairobi were randomly selected, giving five subcounties. In the next stage, the sample was stratified into religions as follows: Protestants, Catholics, Muslims, Hindu, traditionalists, and atheists. Atheism is not a religion, but it will be sampled for the purposes of comparison. The sample size of each religion was determined proportionately, giving 110 Protestants, 80 Catholics, 50 Muslims, 30 Hindus, 30 traditionalists, and 20 atheists.
For Protestants, Catholics, and Muslims, one institution of worship was selected from each of the five subcounties from which 22 Protestants, 16 Catholics, and 10 Muslims were randomly sampled according to age strata. Participants from religious denominations were accessed from places of worship, whereas atheists were purposively selected from the Atheists Association of Kenya social media accounts.
At each of the institutions where actual sampling was done, participants were stratified into the following three age groups: young adults (20–34 years), middle-aged adults (35–64 years), and late adults (65 years and above). After collection and analysis of the quantitative data, qualitative sample of twenty participants was selected by extreme case sampling.
The DAP-R, a 32-item, 7-point Likert scale questionnaire developed by Wong and Recker in 1994,[17] was used in measuring death attitudes, while interview guides were used in collecting qualitative data. The DAP-R measures death attitude on five subscales, namely, fear of death, death avoidance, approach acceptance, escape acceptance, and neutral acceptance. The scale approaches death attitudes from the point of positive emotions (death acceptance) and negative emotions (fear of death and death avoidance). According to Wong and Recker,[17] the five subscales are as follows:
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Neutral acceptance – Death is accepted rationally as a stage of life
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Approach acceptance – Death is accepted as a reward to move to a better place
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Escape acceptance – Death is accepted as a way of running away from suffering life
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Fear of death – Talking about negative thoughts and feelings about the process of dying, as a way of confronting death anxiety
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Death avoidance – Resisting to talk about death as a way of reducing death anxiety.
The reliability of the subscales was determined using alpha coefficients. The alpha scores were fear of death = 0.86, death avoidance = 0.88, neutral acceptance = 0.75, approach acceptance = 0.97, and escape acceptance = 0.84. The subscales recorded strong correlation with similar constructs from other standardized questionnaires.
RESULTS
The study sought to explore the level of negative death attitudes in relation to age group of the participants. Participants were classified into three age groups namely young adults (20–34 years), middle-aged adults (35–64 years), and late adults (above 65 years). Death attitude was measured using the Death Attitude Profile Revised and means were computed ranging from 0 to 7. A mean of 7 indicated the highest intensity of the death attitude, with 0 indicating the lowest intensity of the death attitude.
Negative death attitudes
The study analyzed age differences in death attitudes to ensure clarity of the trends and patterns emerging from the data. Fear of death and avoidance of death were conceptualized as negative attitudes toward death. Figure 1 shows the differences in negative death attitudes such as fear of death and death avoidance.
- Negative death attitudes according to the age of participants
The results indicated that fear of death and death avoidance were more prevalent among young adults (mean = 5.02 and 5.02, respectively) followed by middle-aged adults (mean = 4.42 and 4.22, respectively), with the lowest prevalence being recorded among the late adults (mean = 3.16 and 3.14, respectively). The findings showed that younger participants viewed death as more negative compared to positive. The older adults, on the other hand, viewed death as less negative. The DAP-R score for young adults and middle-aged adults was above average, indicating high intensity in negative attitudes toward death among participants of these age groups. On the other hand, the DAP-R score for late adults was below average, indicating low intensity in negative death attitudes among participants in this age group.
Rationale for negative death attitudes
Participants who reported higher means on death avoidance and fear of death were interviewed for deeper understanding of the motivation behind this trend. They were asked to explain the main reasons for their negative attitude toward death. Their responses were coded and later grouped into themes, after which eight themes emerged. Frequencies of each theme were computed with respect to the age group to which the participants belonged. Table 1 shows the various themes that emerged out of this question.
| Themes | Frequency (%) | ||
|---|---|---|---|
| 20-34 years | 35-64 years | 65 years and above | |
| Unfulfilled life goals | 70 | 25 | 5 |
| Dying process is threatening | 55 | 35 | 10 |
| Family attachment | 39 | 48 | 13 |
| Unresolved family conflicts | 10 | 60 | 30 |
| Families with young children | 5 | 80 | 15 |
| Fear of hell | 20 | 41 | 39 |
| Finality of death (permanency) | 30 | 43 | 27 |
| Unresolved past deaths | 58 | 32 | 10 |
The results showed that some of the major reasons why young adults had negative attitude toward death included unfulfilled life goals (70%), unresolved past deaths (58%), threatening dying process (55%), family attachment (39%), and finality of death (30%). The other reasons that to a small extent informed negative death attitude among the young adults included families with young children (5%) and unresolved family conflicts (10%).
For the middle-aged adults, the major factors that informed negative attitudes included families with young children (80%), unresolved family conflicts (60%), family attachment (48%), finality of death (43%), fear of hell (41%), threatening dying process (35%), and unresolved past deaths (32%), with unfulfilled life goals (25%) being the least determinant of negative attitudes among middle-aged adults.
For the late adults, the prevalence of negative death attitudes was low but still some reasons for this attitude were given. The leading reasons included fear of hell (39%), unresolved family conflicts (30%), and finality of death (27%). The reasons that least informed negative death attitudes among the late adults included unfulfilled life goals (10%), unresolved past death (10%), and threatening dying process (10%).
Unfulfilled life goals
Participants who expressed negative attitude toward death felt that they still had a long way to go in terms of fulfilling their core life goals. Among the young adults, the major life goals to which greater attachment was found included marrying and having own family, completing studies, and getting a decent job with stable income. Majority of the participants reported that these were the core goals of life that they would like to accomplish before death. Many of them indicated that dying without a family would mark the end of their generation as they would have no offspring to advance their lineage. The older participants in this age group were of the view that caring for their family and ensuring the next generation was a goal that they would want to live and see accomplished. One participant said, “I want to have my own family, to have children and nurture them to maturity. Once they are mature to stand on their own and once am I have served the rest of humanity then I will be ready for death. For now that is my focus but not preparing for death” (interviewee, personal communication). Another participant reported,
I do not think my own death is relevant to me now. I have greater things that are not yet accomplished. I have not achieved most of my youthful dreams. Am focusing on these unfinished goals and aspirations before I can start to plan for my own death. If I were to die now, I would die very bitter because I will appear to have failed in life (interviewee, personal communication).
Dying process is threatening
The participants indicated that their negative attitude toward death was as a result of the dying process. They had a general belief that dying is a painful process and going through such a process requires courage. Some of the threatening death experiences cited by the participants included road accidents, plane crush, terror, homicide, and terminal sicknesses, among others. A participant said, “The imagination of going through tragic death experience like road accident is disturbing. I would not want to go through such experience. If there was a peaceful way of dying I would have thought otherwise” (interviewee, personal communication).
Family attachment
Majority of the participants felt that the experience of abrupt disconnection with their family members permanently due to death was extremely disturbing. The bond among family members was seen to be a key deterrent of death acceptance among majority of the participants. Death was seen as an avenue for one to get into a lonely and isolated world where family members would not be accessible. The family environment and relationship among members was highly valued by participants and as a result death was not welcome in any of these families. One of the participants said,
“I fear to be permanently separated from my family members. If I was to die together with my family members and be assured that we will land at the same place, I would not hesitate to die. However the current status where people have to die in shifts and no assurance of meeting again leaves me very worried of my own death” (interviewee, personal communication).
Unresolved family conflicts
The participants reported that presence of serious and unresolved issues in their families kept them in a state of suspense as far as their own death was concerned. This was a common feeling among the middle-aged and late adults. It was the hope of parents to leave peaceful families behind in case of death. Leaving behind disintegrated families was considered a bad legacy for most participants. Families that experienced long-term conflicts among the spouses, siblings or children, and parents appeared to impeded death preparedness of the adults. A participant reported,
“How can I leave my family in its current status where my sons have rebelled against me? It pains me to see this disorder. If we could be able to restore the status of the family to mutual respect and love for one another, the environment would be conducive to think about death” (interviewee, personal communication).
Families with young children
The results indicated that negative death attitude was more prevalent in participants who originated from families with young children. Most adults who were parents of young children expressed fear and avoidance death, citing the pain of leaving their young ones unattended in case of death. It was difficult for these participants to trust anyone else to take care of the young children in the case of death. To others, it was difficult to imagine their children growing without parents. The inability of children to comprehend the death of parents was perceived by participants as more disturbing than death itself. One participant said,
“When I imagine that my young daughter can come home one day find me dead and continue searching for me without and recovering me, I feel so frightened about death. The tears and pain of my children during such a moment are unbearable. I would prefer to bring them up and see them achieve their own independent life then I die a peaceful mother” (interviewee, personal communication).
Fear of hell
Participants from religions that believed in life after death and punishment of evil doers after death had more worry about their status after death. They described hell as a terrible place that would mean eternal suffering without reversal. As a result, those who doubted if they were living according to the teachings of their religions appeared to fear death more compared to those who thought they were living well. Those who had stable families and fulfilled life goals but no assurance of whether they were living according to the teachings of their religion reported negative attitude toward death. It follows that fear of hell was a strong deterrent for positive death attitudes. A participant said,
“The stories I have heard of how hell is are scaring and I fear dying just to find myself in such a place. Sometimes when I compare my life and what the bible teaches I find a lot of discrepancies and this keeps me disturbed. I would like to perfect my life before dying to avoid this kind of harsh punishment” (interviewee, personal communication).
Finality (permanency) of death
The participants reported that the fact that they would cease to exist after death was threatening. They reported that the awareness that death was irreversible and that all senses and body functions will cease working after death meant doom and was intolerable. This was commonly reported by the participants who did not believe in life after death. A participant reported,
“I can't imagine one day lying in a grave with no sense or feeling. Death would have been a bit bearable if one was to be dead for some time and comes back to life or if some senses were functional even after death in order to keep the deceased person connected to the happenings around” (interviewee, personal communication).
Unresolved past deaths
Participants who had experience of past unresolved deaths had negative attitude toward death. Bottled up grief was seen to portray death as an ugly experience that needed to be avoided at all costs. This feeling was common among younger participants who had experienced the death of a family member in their life. A participant narrated,
“I hate to remember how my father was murdered. The picture continually plays in my mind as a movie. I would not want to associate with such an ugly experience. Death can never be good at all as it robbed me and made my life miserable” (interviewee, personal communication).
Positive death attitudes
The study analyzed age differences in death attitudes to ensure clarity of the trends and patterns emerging from the data. Neutral acceptance, approach acceptance, and escape acceptance were conceptualized as positive attitudes toward death. The results of positive death attitudes in relation to the age of participants are shown in Figure 2.
- Death attitudes according to the age of participants
The study found that positive death attitudes were positively related with the age of participants. Older participants reported higher positive death attitude as compared to the younger ones. Neutral death acceptance was lowest among the young adults (mean = 4.38) followed by the middle-aged adults (mean = 4.73), with the highest being recorded by the late adults (mean = 4.92). Approach acceptance was lowest among the young adults (mean = 3.74) followed by the middle-aged adults (mean = 3.80), with the highest being recorded by the late adults (mean = 5.48). Escape acceptance was lowest among the young adults (mean = 4.02) followed by the middle-aged adults (mean = 4.67), with the highest being recorded by the late adults (mean = 5.33). Even though all age groups scored above average on all the three positive attitudes, the late adults recorded the highest intensity of these attitudes.
Rationale for positive death attitudes
Participants who reported higher means on neutral acceptance, approach acceptance, and escape acceptance of death were interviewed for deeper understanding of the motivation behind this trend. They were asked to explain the main reasons for their positive attitude toward death. Their responses were coded and later grouped into themes, after which seven themes emerged. Frequencies of each theme were computed with respect to the age group to which the participants belonged. Table 2 shows the various themes that emerged out of this question.
| Themes | Frequency (%) | ||
|---|---|---|---|
| 20-34 years | 35-64 years | 65 years and above | |
| Reuniting with deceased peers and relatives | 2 | 20 | 78 |
| Meeting the creator | 30 | 37 | 33 |
| Fulfilled past life | 4 | 23 | 73 |
| End to a prolonged miserable life | 10 | 45 | 45 |
| Lack of death awareness | 57 | 25 | 18 |
| Transformation after death | 3 | 37 | 60 |
| Feeling of alienation | 2 | 20 | 78 |
The results showed that some of the major reasons why young adults had positive attitude toward death included lack of death awareness (57%) and meeting the creator (30%). The other reasons that to a small extent informed negative death attitude among the young adults included reuniting with deceased peers and relatives (2%), fulfilled past life (4%), transformation after death (3%), feeling of alienation (2%), and end to a prolonged miserable life (10%).
For the middle-aged adults, the major factors that informed positive death attitudes included end to a prolonged miserable life (45%), transformation after death (37%), meeting the creator (30%), lack of death awareness (25%), and fulfilled past life (23%). The other reasons that to a small extent informed positive death attitudes among middle adults included reuniting with deceased peers and relatives (20%) and feeling of alienation (20%).
For the late adults, the prevalence of positive death attitudes was the highest, and some of the main reasons given included reuniting with deceased peers and relatives (78%), feeling of alienation (78%), fulfilled past life (73%), transformation after death (60%), end to a prolonged miserable life (45%), and meting the creator (33%), with the least reason for positive death attitudes being lack of death awareness (18%).
Reuniting with deceased peers
The results showed that deceased relatives and peers of participants played an important role in determining positive death attitudes among the participants interviewed. Most participants, especially the older ones, reported to be looking forward to their own death as a way of reconnecting with their peers and relatives who had died earlier. Those advanced in age and having experienced loss of their childhood friends and other significant family members were very eager to meet them one day. They believed that through death they would be able to enter the world of the dead to reunite as it was not possible for the deceased to come back. A participant reported,
“I feel fulfilled in life and ready to depart from this world. I feel excited as I near my death as this will facilitate meeting my old time friends and family members who had died earlier. Specifically I want to meet my father who died 15 years ago and my other friends who died before” (interviewee, personal communication).
Meeting the creator
The participants reported to welcome death as it was the only avenue through which one would get to meet their creator. The older generation reported the need to rest from the hard work done in their entire life and proceed to a place of eternal fellowship with God. These were participants who felt that they were in the right standing with their creator and the religious teachings. This urge was demonstrated by a participant who said, “I welcome death since I believe I have lived my life fully. If I were to die today, I would be a fulfilled man. I would rush to the world of the dead confident of living with my God. Meeting the creator was associated with living according to the teachings of one's faith” (interviewee, personal communication).
Fulfilled past life
The participants cited satisfying past life and achievement of core life goals as one of the major factors that facilitated their positive attitude toward death. Majority of these participants fell in the age bracket of 65 years and above. Among the issues cited in support of fulfilled past life included stable family, successful career, grown up children, and good religious and spiritual standing. The participants rated their current life in relation to their childhood dreams and where discrepancy was low, death acceptance was high. Fulfilled past life was interpreted as a job well done, which had the tendency to reduce negative attitude toward death. A participant said, “I have completed my work on earth. My children are adults and self-reliant. I have acquired enough property and I believe I have fulfilled God's will for my life. Even though am not calling for death, I am not scared of death now” (interviewee, personal communication).
Prolonged miserable life
Participants who felt that their current life was uncomfortable tended to have positive attitude toward death. This was a sign of surrender and escape from terrible life that they had tried changing without a success card. It may be argued that miserable life in itself is not a motivator to positive death attitudes, but instead the need to get out of the miserable conditions. A participant reported,
“There is too much suffering to continue admiring to live any longer. I have been through rough time and things have remained the same for quite some years. I do not see the hope and need to the current status to change. If I were to be asked to choose between the current status and death I would chose death at least to have a rest” (interviewee, personal communication).
Lack of death awareness
Some participants reported that they had nothing to do with death because at the moment it was not in their mind. This was more prevalent among the young adults. Majority indicated that at the moment, they were more concerned with living in the present and personal development instead of worrying about end of life. It can, therefore, be argued that focus on life goals by the younger generation is more important than death, which inhibits end-of-life thoughts and positive death attitudes. A participant reported, “I do not think about my death now. I am so committed to achieving my life long dreams and aspirations. I think it is more valuable for me to think about my current life than to spend time thinking about my death” (interviewee, personal communication).
Transformation after death
Participants reported positive death attitudes citing expected transformation after death. Most religions from which participants were selected teach better life after death. Participants from the Christian faith reported to be eager to receive a new body and new mansion in heaven together with other rewards after death. Muslims expressed joy for the expected better life after death in terms of the promised virgins and transformed body. In comparison to the current living conditions, many participants hoped that the next world after death would be a perfect place to live, which influenced the attitude they had toward death. A participant reported,
“My lord awaits me on the day I die with great reward for the life I have lived here on earth. I see myself dressed in white, shining and living in golden mansion with golden streets. I am not scared of death as my death would mean beginning of new life for me” (interviewee, personal communication).
Feeling of alienation
Some participants felt that they do not fit in the current environment as most of their peers were deceased. It was hard for these participants to adjust to social interaction with surviving relatives of totally different generation from theirs. The older participants who had lost most of their peers to death were more comfortable with death and viewed life on earth as strange. They reported feeling of loneliness and void in relating with other people as life had lost meaning without their old-time friends and relatives. A participant reported,
“I miss my departed friends who died long ago. When I remember our childhood play and the time we spend together I long for those days. My current living conditions are not satisfying. I have all the material things I need but separation from my old time friends through death keeps me feeling out of place. I wish I could rejoin them sooner to revitalize my early childhood experiences” (interviewee, personal communication).
DISCUSSION
Studies have been done on the relationship between death attitudes and age, with conflicting findings being reported. Some studies reported a linear relationship between death attitude and age, implying that there was less fear of death among young people as compared to older adults.[1819202122] These studies reported that majority of the young people rarely thought about own death. On the other hand, as one grows older, the reality of mortality becomes clearer, and this elicits various reactions from the individual. William (2016) also reported that death anxiety declined across lifespan. The study further indicated that social support predicted lower death anxiety over time. Similarly, Russac et al.[23] reported greater death anxiety among young adults with significant decline in late adulthood. These results are similar to the findings of the current study, which reported higher negative death attitudes among young adults compared to older adults.
Contrary to these findings, other studies have found a curvilinear relationship between death attitude and age. Middle-aged adults have been found to record the highest levels of fear of death.[2124] Similarly, the validation study of the Death Attitude Profile by Gesser et al.[18] found that fear of death was highest among middle-aged adults and lowest among young adults and the elderly. The rise in fear of death during middle adulthood could be as a result of the onset of decline years combined with anxiety emanating from unfulfilled life goals. In the old age, individuals could have resolved most life of earlier unresolved conflicts, setting the stage for death acceptance.
Other studies dispute the view of existence of an association between death attitudes and age. Feifel and Naggy[25] and Maiden and Walker[26] found that age was not significantly related to death anxiety. The studies showed that both younger and older participants had the tendency to portray fear of death in similar magnitude. The studies concluded that age does not play a significant role in the propagation of death anxiety. These studies have been replicated by more recent studies which reported an insignificant relationship between age and death anxiety.[27] The current study reported contrary findings as significant age differences were reported in both positive and negative death attitudes.
On the rationale for negative death attitudes, Garry (2017) found that older adults with higher death anxiety cited the process of dying, past and future regrets, beliefs about one's self, and the world and coping strategies as the key impediments to positive death attitudes. These findings resonates with the current study which identified unfulfilled life goals, threatening dying process, unresolved family conflicts, permanency of death, and unresolved past deaths as some of the main factors that influenced negative death attitude across lifespan. Fear of hell, family attachment, and families with young children in the current study were found to be consistent with fear of pain and punishment, religious transgressions, and failures and parting with loved ones as identified by Dadfar et al.[28] as reasons for fear of death. The study found that religiosity was associated with higher death acceptance. However, Latha et al.[29] reported that rigid and fundamentalist religiosity was found to predict difficulty in accepting death. The current study did not measure religiosity but still found religious reasons for fear and acceptance of death.
The positive dimensions of the death attitude profile were replicated by the qualitative data in this study. On escape acceptance, it was found that participants welcomed death as a result of prolonged miserable life and feeling of alienation. Approach acceptance of death was expressed as the need to reunite with deceased relatives and peers, meeting the creator, and transformation after death. These findings were consistent with those of the study by Asadpour et al.,[30] who found similar attitudes among medical students in India. The study further found that people who had prior experience of handling death issues reported low scores on escape acceptance. Lin (2003) had earlier reported that religiosity and spirituality influenced both fear and avoidance of death. From the current study, this was confirmed by the fact that some participants feared death as a result of avoiding the punishment of hell.
CONCLUSION
This study found that negative death attitude was rampant during young adulthood with steady decline as age increased. It was also found that positive death attitude was highest during late adulthood and lowest during young adulthood. This implies that mental health practitioners need to target younger adults with death education programs to promote death preparedness and quality dying. For the older adults, there is a need to address life regrets, family conflicts, and past unresolved deaths as some of the ways of enhancing death preparedness. The study recommends that death preparedness programs need to be formulated and promoted across lifespan to enhance the dignity of dying persons and ensuring healthy grieving after death.
Financial support and sponsorship
Funded by International Society for the Study of Behavioral Development (ISSBD) Developing Country Fellowship of 2016-2018.
Conflicts of interest
There are no conflicts of interest.
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