Attitudes of Palestinian and Polish Medical Students Towards Death

Abstract

Attitudes of students of health-related subjects towards the death are an important issue showing the behaviour and values that guide young people in everyday interactions. The study was conducted using the Questionnaire About Attitudes Against Death (DAP-R-PL) among 309 students, including 150 Palestinian from the Faculty of Nursing and Health Sciences and 159 Polish from the Faculty of Health Sciences. It was noticed that the attitude of Death Avoidance is higher in Palestinians than in Poles. The biggest difference between correlation indicators is for the factors fear of death and death avoidance (FD and DA). This value is positive for Palestinian respondents and negative for Polish respondents. The study confirms that the attitudes of students towards death from both universities in the perspective of 5 factors are positive and in future contacts with dying patients they will cope with this challenge.

Keywords

acceptance of death avoidance of death escape from death fear of death medical students

The problem of understanding death always wonders and arouses curiosity. The concept of death is an ontological fact. In every era and in various philosophical and religious systems one can see a differentiated approach of man in this matter. The topic of the end of life is a research problem for many scientists in various scientific disciplines. In European culture, death is perceived on the one hand as something fascinating, and on the other hand as something embarrassing, even pathological (Mir, 2010). Very distant psychological and philosophical theories indicate that issues related to transience and death are associated with the meaning of existence (Schaff, 1961). Interesting is also the theory that says that a person's attitude to death may indicate the state of his search for the meaning of life (Maslow, 1967).

Some scientific theories point to two trends around the topic of death. The first contains the element of impotence over death because it cannot be escaped, and the second tendency includes the element of humanization (Kübler-Ross, 1988). Other authors point out that the problem of attitudes towards death depends on emotional and cultural attitudes. However, when considering the problem of death as a phenomenon, it is also worth distinguishing the biological and religious approach to this state. An example would be research done among American students who generally show existential empathy for dying people and the phenomenon of death itself, feeling sadness and surprise. However, only 8% of students participating in this study revealed their religious attitudes and significant empathy for the phenomenon of dying (Talwalkar et al., 2019). Other researchers dealing with similar issues put forward the thesis that some students show a negative approach to death and often their attitude does not correspond to the declared religious norms. What's more, the researchers reveal that academic youth know and practise religious norms to a small extent and is not able to interpret death phenomenon through their prism (Fenvesh et al., 2019). Another perspective that can be seen when studying the literature on the subject in the space of approach to death is to look at this process from the position of different cultures, and what is associated with the position of different religions.The results of these studies confirm that a religious denomination has statistically significant implications and plays a decisive role in attitudes towards death (Alhawari et al., 2019). In view of the above, equally interesting information is the opinion of medical university students who are preparing not only to accompany seriously ill people, but also in their interactions with patients will rub against death. The results of research carried out at the faculty of health sciences at the University of Spain show that nursing students cope best with the death process compared to pharmacy students. Studies have not shown the impact of age, gender, level of study, or even religion on the level of coping with fear of patient death (Velarde-García et al., 2017). In contrast, research conducted among students of the faculty of nursing and theology in Turkey showed that the majority of students from both faculties are not sufficiently prepared to work with dying people. Research participants highlighted the shortcomings in the space of emotions in such interactions (Bakan & Arli, 2018). Another important challenge that deals with the phenomenon of death is fear of this process. It turns out that in people who have never had contact with dying people this fear is greater. This is confirmed by, among others research conducted on a group of 256 nursing students in the Czech Republic, where a significant group of respondents were found to feel anxious (Bužgová & Janíková, 2017). In the modern world, the phenomenon of death is becoming more common. It is shown in various ways as an event that affects many people and not just older people. Still, many people cause fear that some people want to reduce, e.g. by organizing special training sessions or courses. This confirms the fact of conducting a special course of death and dying for undergraduate students. The result of this special education was to reduce the fear of death and the general fear of this phenomenon (Wallace et al., 2017). Seeking answers to questions about death is part of the whole life process and is generated through culture and especially religion. On the one hand, the opinions of the inhabitants of Europe regarding death are important, where European culture shows the values and norms of behaviour that are becoming relative. However, equally interesting are the attitudes towards the death of Middle Eastern residents, where a diverse culture rich in different religions generates poignant attitudes towards this problem. The research problem undertaken focuses on assessing the attitudes of Palestinian and Polish youth towards death. The authors conducted research among students of the university in Bethlehem/Palestine/and in Szczecin/Poland/. The publication presents behaviour towards fear of death, avoidance, neutral acceptance, escape and total acceptance. The obtained results show, on the one hand, the diversity of students' attitudes towards death, perceived existentially and spiritually, and on the other, the acceptance of inevitability.

Methods and Data

The study was conducted using the Questionnaire Profile of Attitudes Against Death - revised version (DAP-R-PL) Authors: Wong, G.T. Reker, G. Gesser. Translations and adaptations into Polish were made by P. Brudek, M. Sękowski, S. Steuden (The paper questionnaires in English were filled in by students of the Faculty of Nursing and Health Sciences of the University of Bethlehem, while students of the Faculty of Health Sciences from the Pomeranian Medical University completed questionnaires in Polish. The questionnaire contains 32 statements related to different attitudes towards death. Answers to the statements made were given on a scale of 1 to 7, where 7 means: I strongly agree, 6 - I agree, 5 - I rather disagree, 4 - difficult to say, 3 - I rather disagree, 2 - I disagree, 1 - I definitely disagree.

The answer key with appropriately allocated points includes 5 factors:

Fear of death: Fear of Death (FD), which contains 7 statements (contained in questions: 1, 2, 7, 18, 21, 32): death is undoubtedly an unpleasant experience, the prospect of my death gives me anxiety, I'm worried that death is inevitable, I'm very afraid of death, I'm terrified that death will mean the end of everything I know, I'm worried about the uncertainty of what will happen after death.

Avoiding death, which brings together 5 statements (from questions: 3, 10, 12, 19, 26): I avoid the thought of death at all costs, whenever there is a thought about death in my head, I try to push it away, I try not to think about death, I completely avoid thinking about death, I try to have nothing to do with the subject of death.

Neutral acceptance of death, which contains statements (attributed to questions: 6, 14, 17, 24, 30): death should be seen as a natural, undeniable and unavoidable event, death is a natural aspect of life, I am not afraid of death, but I am not i waiting for her, death is part of life as a process, death is neither good nor bad.

Acceptance of death, which includes the answers to questions 4, 8, 13, 15, 16, 22, 25, 27, 28, 31: I believe that I will be in heaven after I die, death is an entrance to a place of ultimate satisfaction, I believe that heaven will be a much better place than this world, death is a union with God and eternal bliss, death brings a promise of a new and glorious life, I look forward to a reunion with my loved ones after I die, I see death as a passage to an eternal and blessed place, death offers a wonderful release of the soul, one thing that gives me comfort in facing death is my belief in the afterlife, I look forward to life after death.

Escape from death, which brings together the answers from questions 5, 9, 11, 23, 29: death will bring an end to all my troubles, death provides an escape from this terrible world, death is deliverance from pain and suffering, I view death as a relief from earthly suffering, I see death as a relief from the burden of this life.

The questionnaire used for the study also contained questions about the gender and age of students. The research was conducted at the beginning of 2020 at both universities.

309 students participated in the study, including 150 Palestinian students: 88 women and 62 men and 159 Polish students: 129 women and 30 men at the age of 19-38.

Results

The results of the study were obtained from the Questionnaire About Attitudes Against Death (DAP-R-PL). However, the Cronbach’s alpha measure was used to measure the scale reliability of the survey. Quantitative data are given as mean ± standard deviation and in percentages. The One-sample Kolmogorov – Smirnov test showed that none of the analyzed distributions are close to the normal distribution (p < 0.05), therefore the Mann-Whitney test, One-way ANOVA and Tukey HSD test were used to analyze the differences between the distributions. The Pearson correlation coefficient was used to examine the correlation between DAP-R-PL factors. A significance level of 0.05 was assumed for all tests. The value of Cronbach’s alpha is 84.7%, so overall credibility of the questionnaire was achieved. The reliability of the scale (Cronbach’s alpha) for individual factors, i.e. fear of death, death avoidance, natural acceptance, approach acceptance and escape acceptance, is respectively: 0.77, 0.78, 0.82, 0.89 and 0.75. The sample consists of 309 people, the response rate was 100%. Respondents of Polish origin constitute 51.5% and 48.5% are Palestinians. According to the results of this study, the average and standard deviation of the age of the subjects was 22.25 ± 3.35, and the median, dominant, minimum and maximum age were 22, 23, 18 and 38, respectively. In addition, 62.5% of respondents (193 respondents) were in the 20-24 age group. The majority of samples were women (70.2%, 217 respondents). About 41.7% are women from Poland and 28.5% are women from Palestine. According to the DAP-R questionnaire, attitude to death was assessed using 5 factors: fear of death, death avoidance, natural acceptance, approach acceptance and escape acceptance. The mean value and standard deviation for fear of death, death avoidance, natural acceptance, approach acceptance, and escape acceptance of the obtained results were respectively: 4.18 ± 1.30, 3.95 ± 1.43, 4.37 ± 1.70, 3.83 ± 1.37 and 4.02 ± 1.41.

Studies have shown that there was no statistically significant difference between male and female responses to Fear of Death. Similarly, the fear of death of Poles and Palestinians does not differ statistically. Whereas the average Death Avoidance value is higher among Palestinians than among Poles, this difference is statistically significant (p = 0.001) (Table 1).

Table 1.

Frequency Distribution of Samples Based on Average Death-Rate Results.

DAP-R	Mean ± SD
Fear of death	4.18 ± 1.30
Death avoidance	3.95 ± 1.43
Neutral acceptance	4.37 ± 1.70
Approach acceptance	3.83 ± 1.37
Escape acceptance	4.02 ± 1.41

There was no statistically significant difference in avoiding death between men and women. Statistical tests showed statistically significant differences between the responses of Poles and Palestinians regarding Neutral Acceptance and Approach Acceptance, in both cases p < 0.001. This means that Poles have a higher level of Neutral Acceptance and Approach Acceptance than Palestinians. For Neutral Acceptance and Approach Acceptance, male and female responses are also statistically significantly different (p < 0.001 and p < 0.03, respectively). Higher mean values for Neutral Acceptance and Approach Acceptance were obtained for women. So men have lower levels of Neutral Acceptance and Approach Acceptance than women. In the case of Escape Acceptance, statistical tests did not show significant differences in responses based on gender and country of origin (Table 2).

Table 2.

Comparison of Mean of the DAP-R Questionnaire With Country of Origin and Gender.

				Mann–Whitney test		One-way ANOVA test
DAP-R	Variable	Mean ± SD	N	z-value	p	F	df	p
FD	Country of origin
	Poland	4.28 ± 1.40	159	0.23	1.19	2.10	1	0.148
	Palestine	4.07 ± 1.17	150
	Gender
	Male	4.21 ± 1.18	92	−0.43	0.67	0.06	1	0.815
	Female	4.17 ± 1.34	217
DA	Country of origin
	Poland	3.70 ± 1.50	159	−3.18	0.001	10.22	1	0.0015
	Palestine	4.21 ± 1.30	150
	Gender
	Male	3.90 ± 1.38	92	0.29	0.77	0.14	1	0.705
	Female	3.97 ± 1.46	217
NA	Country of origin
	Poland	5.59 ± 1.08	159	12.85	<0.001	378.80	1	<0.001
	Palestine	3.07 ± 1.20	150
	Gender
	Male	3.73 ± 1.66	92	4.15	<0.001	19.75	1	<0.001
	Female	4.64 ± 1.64	217
AA	Country of origin
	Poland	4.12 ± 1.48	159	4.47	<0.001	15.14	1	<0.001
	Palestine	3.52 ± 1.18	150
	Gender
	Male	3.56 ± 1.36	92	2.30	0.021	5.01	1	0.026
	Female	3.94 ± 1.37	217
EA	Country of origin
	Poland	3.88 ± 1.52	159	−1.78	0.075	2.95	1	0.087
	Palestine	4.16 ± 1.27	150
	Gender
	Male	4.04 ± 1.42	92	−0.28	0.780	0.028	1	0.866
	Female	4.01 ± 1.40	217

For Neutral Acceptance and Approach Acceptance, the p-value corresponding to the F statistic for the One-way ANOVA test is lower than 0.05, suggesting that the responses of one or more age groups in these two cases differ significantly. The Tukey HSD test performed for Neutral Acceptance showed statistically significant differences between the mean values of responses of people under 20 years of age with an age group of 20–24 years, p = 0.001. In addition, for Neutral Acceptance significant differences were found between the average groups of people under 20 years of age and the group over 24 years old, p = 0.001. There was no significant difference for Neutral Acceptance between the age groups 20–24 years and above 24 years. However, for Approach Acceptance, the Tukey HSD test showed a significant difference in responses for the age groups below 20 years and 20–24 years (p = 0.001). In other cases, no statistically significant differences were found for Approach Acceptance. There were no statistically significant differences between the results for the age groups corresponding to Fear of Death, Death Avoidance and Escape Acceptance (Table 3).

Table 3.

Comparison of Mean of the DAP-R Questionnaire With Age.

				One-way ANOVA			Tukey HSD test
							AvsB		AvsC		BvsC
DAP-R	Variable	Mean ± SD	N	F	df	p	Q	P	Q	P	Q	p
FD	Age
	<20 years old	4.12 ± 1.20	74	0.23	2	0.798
	20-24 years old	4.22 ± 1.30	193
	>24 years old	4.11 ± 1.46	42
DA	Age
	<20 years old	4.03 ± 1.33	74	0.73	2	0.484
	20-24 years old	3.97 ± 1.41	193
	>24 years old	3.71 ± 1.67	42
NA	Age
	<20 years old	3.28 ± 1.42	74	26.1	2	<0.001	8.71	0.001	9.05	0.001	3.28	0.055
	20-24 years old	4.60 ± 1.59	193
	>24 years old	5.22 ± 1.78	42
AA	Age
	<20 years old	3.40 ± 1.12	74	6.70	2	0.001	4.90	0.001	1.08	0.705	2.71	0.136
	20-24 years old	4.04 ± 1.32	193
	>24 years old	3.60 ± 1.79	42
EA	Age
	<20 years old	4.08 ± 1.31	74	0.23	2	0.797
	20-24 years old	4.02 ± 1.42	193
	>24 years old	3.90 ± 1.53	42

Note: A is “<21 years old”, B is “2–-24 years old”, C is “>24 years old.” The results showed that there is a direct and significant relationship between age and neural acceptance (r = 0.384, p <0.001).

There was no correlation between the other 4 factors (p > 0.05). In addition, the results of the Pearson correlation coefficient showed that there is a direct significant relationship between fear of death and death avoidance (r = 0.593, p < 0.001) and fear of death and Approach Acceptance (r = 0.161, p = 0.005). The results of the Pearson correlation coefficient showed that there is a negative correlation between death avoidance and Neutral Acceptance (r = −0.187, p = 0.001). In addition, there is a direct significant relationship between Neutral Acceptance and Approach Acceptance (r = 0.305, p < 0.001) and Approach Acceptance and Escape Acceptance (r = 0.390, p < 0.001) (Table 4).

Table 4.

The Relationship Between Age and the Dimensions of Attitudes Toward the Death.

	Age	Fear of death	Death avoidance	Neutral acceptance	Approach acceptance	Escape acceptance
Age
r	1	0.045	−0.069	0.384	0.029	−0.076
p		0.431	0.225	<0.001	0.616	0.182
N	309	309	309	309	309	309
Fear of death
r		1	0.593	0.017	0.161	0.0001
p			<0.001	0.768	0.005	0.998
N		309	309	309	309	309
Death Avoidance
r			1	−0.187	0.108	0.065
P				0.001	0.059	0.254
N			309	309	309	309
Neutral acceptance
r				1	0.305	0.086
P					<0.001	0.133
N				309	309	309
Approach acceptance
r					1	0.390
p						<0.001
N					309	309
Escape acceptance
r						1
P
N						309

Discussion

In this study, the results show that students of both universities are characterized by a similar neutral attitude towards the phenomenon of Fear of Death. It should be added that the respondents of both universities are preparing for work with the patient in various situations and some of them will experience death while practising their profession. On the one hand, the level of fear of death indicated by them is natural, and on the other hand it can be leveled by existential dealing with this phenomenon. Some scientists believe that fear of death is natural and common and may have different dimensions and intensities. There can also be many reasons for being afraid of death. Personal fear of losing yourself, fear of suffering and pain or loss of salvation - these are just some aspects of fear. Other studies in this perspective suggest that fear of death may result from the loss of self-esteem, success and the loss of everything that was previously human property (Erikson, 1993). It can also be one of the biggest anxieties that is difficult to control (Tassell-Matamua & Lindsay, 2016).

That is why, among other things, it is recommended that the contents of medical study programs should include contents that will help shape good relationships with dying people (Bermejo et al., 2018). The results of the study also showed that Polish and Palestinian students maintain a similar attitude towards the problem of death avoidance (Death Avoidance: DA). The values obtained in this space indicate a neutral attitude towards this problem. These behaviours may result from the young age of respondents and an immature view of reality, where the subject of death does not seem to fit into everyday existence. It can be assumed that the attitude of Palestinian youth may reflect their real experience of the image of death or viewed through the media. Researchers dealing with this issue point out that the above student attitudes may change to more liberal as a result of interaction with images of suffering and dying people (Martí-García et al., 2017). It has been proved that watching photographs depicting death affects the emotional behaviour of viewers and depends on the degree of suffering of the man depicted in the paintings (Khurshid & Rishabh, 2014; Martí-García et al., 2015). Based on the data obtained, significant differences in the neutral acceptance of (Neutral Acceptance: NA) deaths by students can be seen. Polish students show a higher degree of neutral acceptance of death than Palestinian students. The attitude of Palestinians may correspond to their existential situation resulting from the military conflict with Israel. What's more, living in constant tension and danger of losing their lives, they oppose the neutral acceptance of death, because life is a value for them that must be constantly monitored. It can be assumed that Palestinian youth emphasize the thesis that they are not afraid of death, but they are not waiting for it. Polish students have shown greater interest in a neutral attitude towards death, which may reflect their intense religious commitment. This corresponds to the results of research conducted among religiously involved people, where the attitude of accepting death as a natural stage of existence is noted (Dezutter et al., 2008). In this perspective, death is considered an inseparable stage of life, which at some point ends. It is an unchanging element of life that affects everyone sooner or later. A neutral approach to death can also be the result of a mature view of human existence (Hooper & Spilka, 1970). In the conducted research it can be noticed that Palestinian youth in comparison with Polish youth show greater interest in final matters, expressing their attitude of faith in happiness after death. The results obtained indicate that Palestinians more strongly believe that after death they will be in heaven, that heaven will be a much better place than this world, and death is associated with entering the state of greatest satisfaction and is union with God and eternal happiness. The death brings the promise of a new and wonderful life, and that after death they expect to meet again with those they love. They see death as a transition to an eternal and blessed place. The attitudes presented correspond with other studies that show the correlation between religiosity and fear of death. Scientists argue that individual differences in religious fundamentalism translate into the essence of mortality and can affect religious apocalyptic beliefs. It is assumed that for people with higher religious fundamentalism, the fear of death indicator increases apocalyptic beliefs (Routledge, 2018). It is worth adding that the researchers emphasize that the empirical definition of the terms “religiosity” and “fear of death” generates many inaccuracies and often causes prejudices and requires greater conceptual transparency and methodological innovation (Jonathan & Halberstadt, 2017). Another study shows that religious faith alleviates anxiety about death among both believers and non-believers. These findings suggest that religious beliefs can alleviate the fear of death by offering symbolic and literal immortality, respectively (Jackson et al., 2017). In addition, research results have shown that the attitude of acceptance of escape from death (Escape Acceptance) of both Palestinian and Polish respondents is similar and can be described as neutral. Scientists argue that the neutral attitudes of young people towards the end of life can be a reflection of their daily existence and practised values. In the case of Palestinian youth, one can see the impact of the existential images of death to which they are accustomed. Therefore, the opinion of researchers dealing with the end of human life is interesting.

They emphasize that the surprise, suffering and moral paradox that often surround death directs people to seek the meaning of life. They argue that in this process, people derive strength from cultural links related to death. More specifically, they speak of cultural affordances related to death, which are realized through three thanatological cultural niches. The first is a canonical niche, which includes affordances rooted in religious authority and established tradition. The second is a utility niche, which is created by affordances based on rational and utilitarian reasoning. The last expression niche focuses on affordances based on authentic self-expression. It is interesting that the qualitative analysis of people facing death approaching shows that they have used cultural affordances from various cultural niches, which in turn can lead to mutually inconsistent personal concepts of death (Fortuin et al., 2016). In addition, the results show that the responses obtained through the DAP-R research tool in terms of correlation are relatively independent for both Polish and Palestinian students. It should be noted that the biggest difference between correlation indicators occurs for the factors fear of death and death avoidance (FD and DA). At the same time, the indicator value is negative for Polish respondents and positive for Palestinian respondents. Noteworthy is the moderately positive relationship between factors: fear of death and avoidance of death. (FD and DA) The strongest relationship between Palestine and Poland for FD and DA factors is also interesting. However, a more thorough analysis of the link between fear of death and avoidance of death requires detailed study of the individual components of these two factors. It is also interesting that for respondents from Palestine all values of correlation coefficients are positive, while for respondents from Poland there are correlation coefficients with negative values. Similarly, a positive correlation coefficient for death acceptance and escape acceptance (AA and EA) is noticeable. Analyzing the other factors from the DAP-R research tool, a low correlation indicator is noticed. Based on the results presented, it can be concluded that students of medical faculties of different cultures have revealed their positive axiology in the space of death, which in turn can contribute to building and nurturing responsible interactions with dying people.

Conclusions

The results from the conducted research show that students' attitudes towards death from both universities in a five-dimensional perspective are positive. Presumably, they will overcome this challenge in contact with dying patients. However, a higher degree in Death Avoidance among Palestinian students may reflect their existential experience of this phenomenon. In favour of students from Palestine are their religious attitudes regarding eschatology, which in turn may support their interaction with dying people.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Paulina Zabielska

Author Biographies

Krzysztof Zdziarski, Fr, PhD, Subdepartment of Social Medicine and Public Health, Department of Social Medicine of the Pomeranian Medical University in Szczecin. His research interests are focused on social medicine, especially psychosocial and health problems of particular social groups, as well as problems related to loneliness and death.

Mariam S. Awad is dean of Nursing & Health, Chairperson of Nursing and Midwifery, Lecturer. Her research interests are focused on problems related to the performance of medical professions, especially nurses and midwives, and on meeting the biopsychosocial and spiritual needs of patients.

Marek Landowski, PhD, faculty of Computer Science and Telecommunications, Maritime University of Szczecin. His research interests are focused on the construction of decision support systems and autonomous systems, algorithms and image processing methods, and the practical application of artificial intelligence methods and tools in technical systems, including the area of maritime transport.

Paulina Zabielska, PhD, Since 2013, employee of Subdepartment of Social Medicine and Public Health, Department of Social Medicine of the Pomeranian Medical University in Szczecin. Her main point of interest in research are the issues concerning public health and environmental medicine. Author of publications raising issues concerning elderly health in regard to biopsychosocial factors, medical and psychosocial determinants of population health.

Beata Karakiewicz, professor, dean of the Faculty of Health Sciences at Pomeranian Medical University in Szczecin since 2012. Since 2005, the head of the Subdepartment of Social Medicine and Public Health, Department of Social Medicine. Her main point of interest in research are the issues concerning public health and environmental medicine. Author of many publications touching on the problems of disabled people - both physically and mentally, the chronically ill, people addicted to psychoactive drugs and HIV-positive people.

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