Death Anxiety in Muslim Iranians: A Comparison Between Youths,Middle Adults,and Late Adults

Abstract

The study aimed to examine the levels of death anxiety between three age groups and compare gender-related differences among Iranian population. A total of 453 participants (252 college students, 55 middle-aged, and 146 old-aged) answered the Arabic Scale of Death Anxiety (ASDA). Significant differences were found between youths and old-aged samples and between middle-aged and old-aged samples on the ASDA scale. Old-aged persons showed more death anxiety than youths and middle-aged persons. There were also significant differences between men and women in total scores of the ASDA scale; men had more death anxiety than women. There were significant associations between age, gender, and death anxiety total scores. Limitations of the study include the use of a self-report scale, selection of a nongeneral nonclinical population, a Muslim religion, and an Iranian culture. Present results can be considered for psychological therapies for reducing death anxiety and pathways to death acceptance in Iranian people and for carrying out cross-cultural studies in other Asian, Arabic, Eastern, and Western countries with shared and nonshared religions and cultures in future studies.

Keywords

death anxiety age groups Muslim Iran

Introduction

Death anxiety is the anticipation, awareness, and nonexistence issues related to death and dying or beliefs, attitudes, images, and thoughts concerning death, dying, and what happens after death. Death anxiety has emotional, cognitive, motivational, and behavioral dimensions (Corr & Corr, 2013; Lester, 2015). Thinking about death causes a different degree of anxiety for different individuals, depending on factors such as age, gender, education, religion, culture, health, and psychosocial variables (Dadfar & Lester, 2017; Hoelterhoff & Chung, 2013; Ajmal & Khawaja, 2012; Hasan Zehi, 2012). Death anxiety is culturally shaped, as culture establishes a composite of different meanings and beliefs toward death. Death anxiety is subjective to the respective cultures (Ghalebandi, 1988; Scalpello Hammett, 2012). On the Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) and Death Attitude Profile-Revised (DAT-R), Braun, Gordon & Uziely (2010) revealed that culture and religion may be key to attitudes toward death. It seems that age is more important factor than religiosity (Démuthová, 2014). Several studies have shown that when death awareness and its associated anxiety are increased, individuals respond by defending or intensifying their cultural beliefs (Sridevi, 2014a, 2014b; Sridevi & Swathi, 2014). Although there are exceptions, it is possible to summarize the association between death anxiety and several demographic and experiential factors (Bharathi, Sridevi, & Kumar, 2015; Cartwright, 1991; Cicirelli, 1999; Harrawood, White, & Benshoff, 2008; Madnawat & Kachhawa, 2007; Momtaz, Haron, Ibrahim, & Hamid, 2015; Rasmussen & Christiane, 1996; Roshani & Naderi, 2011; Singh, 2013).

Kastenbaum (2000) reviewed studies on fear of death in general population and showed that fear of death is common in general population; women had higher fear of death than men; in cross-sectional studies, elders had no higher fear of death than youths; higher educational and socioeconomic levels were associated with lower fear of death; and high level of religious beliefs and participation in religious activities were not associated with low level of fear of death. In a cross-cultural comparison of death anxiety, Lester, Templer, and Abdel-Khalek (2007) reported that there were strong sex differences in death anxiety and an association between the Death Anxiety Scale (DAS) scores of men and women. Studies of Abdel-Khalek and Lester (2009); Eshbaugh and Henninger (2013); and Iverach, Menzies, and Menzies (2014) have shown that females typically report higher levels of death anxiety than males; higher education and socioeconomic status are moderately associated with lower levels of death anxiety; and older people do not typically report higher death anxiety than younger people.

Pierce, Cohen, Chamber, and Meader (2007) reported that women high school and college students had higher fear of death than men. Tavan, Jahani, and Hekmatpou (2014) found that the academicians’ views about death concept that originated from their belief in resurrection, positive, spiritual, and death were considered as a stage in the evolution of mankind. On the Collett–Lester Fear of Death Scale (CLFDS), Lester (2015) reported that fear of death was not affected by self-construing in priming students. On the Multidimensional Fear of Death Scale (MFODS) and the Revised Death Anxiety Scale, Nienaber and Goedereis (2015) investigated the association between level of education and self-reported levels of anxiety regarding death of self and others among college students. Results showed that undergraduate students and graduate students did not differ on fear of being destroyed, but graduate students reported lower levels of death anxiety on all remaining measures. The aim of study was to examine the levels of death anxiety between three age groups and to compare the gender-related differences among Iranian youths, middle-aged, and old-aged samples.

Materials and Methods

Participants

The study was a cross-sectional, descriptive study. A sample of 252 volunteer Iranian college students (youths), 55 middle-aged, and 146 old-aged individuals took part in the study. They were selected by a convenient sampling and completed the Arabic Scale of Death Anxiety (ASDA).

The students were selected from the colleges at the Iran University of Medical Sciences. The middle-aged and old-aged cohort comprised persons who had come to the neighborhood parks to leisure, recreation, and the activities done for enjoyment when they were not working. The study is limited to the persons located at Tehran city.

The mean age of youths was 25.8 years (SD = 5.3); 47.9% were males; 71.5% were studying to be general physicians, 13.1% clinical psychology, 1.1% mental health, and 8.6% other.

The mean age of the middle-aged sample was 52.63 years (SD = 4.52); for men 52.25 years (SD = 4.70) and for women 55.28 years (SD = 1.38); 85.7% were male, and 14.3% were female. Most of them had a diploma degree (53.2%) and were married (91.8%).

The mean age of the old-aged sample was 68.58 years (SD = 7.10); for male 68.81 years (SD = 7.44) and for female 68.28 years (SD = 6.76). Eighty (58%) were male, and 58 (42%) were female. The majority of them were married (n = 107; 75%) and were diploma holders (n = 56; 39%).

The age range for the entire sample was from 17 to 90 years, and the mean age was 45.15 years (SD = 20.26); the age range for men was from 18 to 90 years, and the mean age was 44.91 years (SD = 20.47); the age range for women was from 17 to 85 years, and the mean age was 44.25 years (SD = 20.20). And 56.9% were male, and 43.1% were female.

The ASDA

Demographic characteristics of the sample include age, gender, education status, and marital status. The ASDA which was developed by Abdel-Khalek (2004) and validated in the Egypt, Kuwait, Syria, Turkey, and Iran countries was used. It has 20 items, and each item is answered on a 5-point intensity scale anchored by 1 (no) and 5 (very much). Good validity with other scales and reliability by Cronbach’s alpha and test–retest methods have been reported for the ASDA (Abdel-Khalek, 2004; Abdel-Khalek & Al-Kandari, 2007; Abdel-Khalek, Lester, Maltby, & Tomás-Sábado, 2009; Sarıçiçek Aydoğan, Gülseren, Öztürk Sarıkaya, & Özen, 2015; Qiu, Zhang, Lin, Ban, Wong, et al., 2016; Dadfar, Lester & Bahrami, 2016; Dadfar & Bahrami, 2016; Dadfar, Abdel-Khalek, Lester & Atef Vahid, 2017). In the present study, Farsi version of the ASDA was used (Dadfar, et al., 2017, 2016; Dadfar, & Bahrami, 2016).

Results

The ASDA scores ranged from 20 to 98 for the entire sample. The mean scores of the ASDA were 44.83 (SD = 16.33); for youths 41.40 (SD = 12.73), for middle-aged 43.94 (SD = 14.90), and for old-aged 51.09 (SD = 20.19).

Findings showed that the youths did not have a significantly higher mean ASDA total score than middle-aged persons (t = 1.17, p > .01). The youths had a significantly lower mean ASDA total score than old-aged persons (t= −5.86, p < .001). The middle-aged individuals had a significantly lower mean ASDA total score than old-aged individuals (t = 2.73, p < .007; see Table 1).

Table 1.

Mean and Standard Deviation of the Arabic Death Anxiety Scale in Iranian Youths (N = 252), Middle-Aged (N = 55), and Old-Aged (N = 146) Samples.

Arabic Scale of Death Anxiety
Youths		Middle-aged		t	p
M	SD	M	SD	t	p
41.40	12.73	43.94	14.90	1.17	–
Youths		Old-aged
M	SD	M	SD	t	p
41.40	12.73	51.09	20.19	−5.86	.001
Middle-aged		Old-aged
M	SD	M	SD	t	p
43.94	14.90	51.09	20.19	2.73	.007

There were significant differences between three age groups (youths, middle-aged, and old-aged persons) on the ASDA (F = 17.56, df = 452, p <.000; see Table 2).

Table 2.

One-Way ANOVA Comparison of Three Age Groups (Youths, Middle-Aged, and Old-Aged Persons) on the Arabic Scale of Death Anxiety.

Source	SS	df	MS	F	p
The Arabic Scale of Death Anxiety
Between groups	8,731.70	2	4,365.85	17.56	.000
Within groups	111,868.20	450	248.59
Total	120,599.91	452

Note. ANOVA = analysis of variance.

There were significant differences between youths and old-aged individuals and between middle-aged and old-aged individuals at the .05 level. Old-aged individuals showed more death anxiety than youths and middle-aged individuals. There was no significant difference between youths and middle-aged individuals (see Table 3).

Table 3.

Post Hoc Test (Scheffe) for Multiple Comparisons of Three Age Groups (Youths, Middle-Aged, and Old-Aged Persons) on the Arabic Scale of Death Anxiety.

Scheffe		Mean difference	SE	Sig.	95% Confidence interval
Pair		Mean difference	SE	Sig.	Lower bound	Upper bound
Youths	Middle-aged	−2.54	2.34	.557	−8.30	3.22
Youths	Old-aged	−9.69^a	1.63	.000	−13.71	−5.66
Middle-aged	Youths	2.54	2.34	.557	−3.22	8.30
Middle-aged	Old-aged	−7.15^a	2.49	.017	−13.27	−1.02
Old-aged	Youths	9.69^a	1.63	.000	5.66	13.71
Old-aged	Middle-aged	7.15^a	2.49	.017	1.02	13.27

^aThe mean difference is significant at the .05 level.

The mean score of the ASDA for males was 46.78 (SD = 17.97) and for females was 41.50 (SD = 12.67). Males had a significantly higher mean ASDA total score than females. These differences were significant at .001 level (t= −3.44, p < .001; see Table 4).

Table 4.

Mean and Standard Deviation of the Arabic Death Anxiety Scale in Iranian Males (N = 250) and Females (N = 189).

Arabic Scale of Death Anxiety
Male		Female		t	p
M	SD	M	SD	t	p
46.78	17.97	41.50	12.67	−3.44	.001

A significant correlation exists between total scores of death anxiety and age (r = .181, p < .01) and death anxiety and sex (r = −.162, p < .01) in Iranian samples (see Table 5).

Table 5.

Pearson’s Correlation (r) Between Age, Sex, and the ASDA Total Score.

Demographic characteristics	r with ASDA
Age	.181^a
Sex	.162^a

Note. ASDA = Arabic Scale of Death Anxiety.

^aCorrelation is significant at the .01 level (two-tailed).

Discussion

Our study showed that there were significant differences between youths and old-aged individuals and between middle-aged and old-aged individuals. Old-aged individuals showed more death anxiety than youths and middle-aged individuals. There was no significant difference between youths and middle-aged individuals. Our results are not similar to previous studies. These differences can justify to more fear of dead people and tombs; fear of lethal disease and postmortem events; death fear according to the ASDA; possible reasons for fearing of death such as more fear of failing to complete life work, fear of pain and punishment, religious spiritual transgression, fear of losing worldly involvements, and parting from loved ones; lower levels of death acceptance, also some demographic, psychological, and personality factors such as coping mechanisms, defense mechanisms, psychosocial maturity, being single, social intelligence, and emotional intelligence in Iranian old-aged samples.

Overall, origin of psychological anxiety and stress in elderly is focused on the lack of change and compensation in the life and death anxiety. Elders review of their life experiences and memories. They understand that there is no chance to compensate for their mistakes. Therefore, fear of death can anxious them. A negative relationship is often seen between age and death anxiety such as younger populations (primarily high school and college). Adolescents may at the same time harbor a sense of immortality and experience a sense of vulnerability and incipient terror but also enjoy transforming death-related anxiety into risky death-defying activities. What people fear most about death often changes with age? Young adults are often mostly concerned about dying too soon before they have had the chance to do and experience all they have hoped for in life. Adult parents are often more likely to worry about the effect of their possible deaths upon other family members. Elderly adults often express concern about living too long and therefore becoming a burden on others and useless to themselves. Furthermore, the fear of dying alone or among strangers is often more intense than the fear of life coming to an end. Knowing a person’s general level of anxiety, then, does not necessarily identify what it is that most disturbs a person about the prospect of death (Bahrami, Dadfar, Lester, & Abdel-Khalek, 2014; Démuthová, 2014). Baum and Boxely (1984) reported that elderly with sound emotional health, who are married, and with more number of children received lower death anxiety scores. Elders who perceived time as slow and those who lived in institutions tend to feel more anxious about death. Elderly with satisfactory family ties and more life satisfaction received less death anxiety scores.

After going through all the ways, accepting death also gives great anxiety and fear to the elderly people. Each individual varies from one another. People afflicted with death anxiety may spend a large amount of time obsessing over death or trying to avoid talking about death. Death anxiety becomes a problem when it stands in the way of experiencing life. How people live foreshadows how they die. When people live a meaningful life, they will leave a meaningful life. If they can answer these questions affirmatively, then they know how to live and die well. Have they lived the life they have always wanted to live? Have they lived a life that is worth living? Do they have the faith to embrace death with joy and hope (Berk, 2007)?

Sarvandian and Hassanpor (2003) found a relation between loneliness and fear of death among aged residents of care facility residency. Paimanfar, Ali Akbari Dehkordi, and Mohammadi (2013) found that elderly who had stronger faith and religious attitude reported a more sense of meaning in life and feeling less lonely when compared with other older adults.

Death in old age is often a protracted affair rather than a clear-cut process that can allow patients and those bereaved to go through the classic stages (Nuland, 1994). Daniel J. Levinson (1977, 1986) has said that the developmental task for the stage of late adulthood is to come to terms with life’s end. Erik H. Erikson (1968) stated that in this stage, some people may become depressed or preoccupied with death. Lower ego integrity, more physical problems, and more psychological problems are predictive of higher levels of death anxiety in elderly people (Fortner & Neimeyer, 1999).

Tang, Wu, and Yan (2002) reported that younger Chinese college students when compared with older participants tended to be more death anxious. Those with low levels of self-efficacy and external health control orientations were more likely to report a high level of death anxiety. Suh (1987) reported that there was a relationship between death anxiety, life satisfaction, and locus of control in Korean and American older adults. Kim and Min (2005) showed that gender and personality have influence on fear of death and death acceptance among young adults. Maxfield et al. (2007) indicated that elders used lower defense mechanisms to death when compared with young people.

There is no consistent increase in death anxiety with advancing adult age. If anything, older people in general seem to have less death anxiety (Christin, 2011; cited in Scalpello Hammett, 2012). Azaiza, Ron, Shoham, and Tinsky-Roimi (2011) reported bereaved elderly Israeli parents had significantly higher dying anxiety scores than nonbereaved parents, but there were no significant differences between the two groups in death anxiety. Ghorbanalipoor, Borjali, Sohrabi, and Falsafinejad (2010) indicated that young adults with death anxiety when compared with older adults with death anxiety showed high rate of health-promoting behaviors. On the CLFDS, Naderi and Roushani (2010) found that there was no significant correlation between social intelligence and death anxiety in elder women. Rasquinha and Acharya (2013) reported that there was a relationship between depression and death anxiety among elderly. Lyke (2013) reported that search for meaning in life was significantly associated with fear of dying and death in young adults. Sridevi and Swathi (2014) showed that 47.5% elders had mild level of death anxiety and 52.5% had moderate level of death anxiety in both institutionalized and noninstitutionalized elders. There was no significant difference in death anxiety among institutionalized and noninstitutionalized elders. There was no significant difference in death anxiety and death depression among institutionalized elders based on gender, but noninstitutionalized male elders had significant death anxiety than female elders. There was no significant difference between death anxiety and death depression based on age, socioeconomic status, and educational background of the elders. There was a correlation between death anxiety, death depression, and geriatric depression, and no significant difference was found between death anxiety, death depression, geriatric depression, and suicidal ideation based on age of the elders (Sridevi, 2014a, 2014b, 2014c, 2014d, Sridevi & Swathi, 2014).

On the DAS, Çelik, Ünsal, and Çağan (2014) reported that students of the school of health, who were under the age of 20, had higher levels of death anxiety. Students who had experienced in dealing with the dying patients and their relatives as to be afraid to see a dying patient, cannot say the right things to relieved the patients’ relatives, not want to care to the dying patient, not to see while preparing for the discharge died, afraid of dead body had higher levels of death anxiety. On the CLFDS, Amjad (2014) reported that the Pakistani middle-aged and old-aged people had lower level of death anxiety than adolescents. On the DAS, Death Depression Scale (DDS), and Death Obsession Scale (DOS), Bahrami et al. (2014) reported that Iranian older adults showed death distress. The study of Nouhi, Karimi, and Iranmanesh (2014) showed that fear of death in the elderly group settled in city houses was higher than elderly settled in the elderly’s home. Death anxiety is related to the threat of nonexistence and to fears from an unknown afterlife, and this anxiety can lead to ageism, a prejudice, or discrimination on the basis of a person’s age (Bodner, Shrira, Bergman, Cohen-Fridel, & Grossman, 2015). Garbay, Gay, and Claxton-Oldfield (2015) showed that there were no significant differences in levels of death anxiety or empathy between France hospice volunteers, nonhospice volunteers, and nonvolunteers. In study of Ron (2016), elders and adult girls showed the highest death anxiety levels, and elderly population and Arab population were at high risk to death anxiety.

We found that there were significant differences between men and women in total scores of the ASDA; men had more death anxiety than women. Consistent with our findings, Lester (1971) reported that male students were more likely to think about death than were females but had less negative effective reaction to death. Our results are not similar to previous studies. A widely cited early review by Polack (1980) concluded that most previous studies reported gender differences, with women consistently reporting greater death anxiety than men. In his commentary on death concern, Kastenbaum (2000) found the gender effect is so consistent that, “in lieu of impressive data to the contrary, it seems reasonable to conclude that the higher self-reported death anxiety for women is a robust finding (p. 37).” Results from Irish and Canadian students suggested that the effect generalizes beyond American culture (Lonetto, Mercer, Fleming, Bunting, & Clare, 1980). The gender differences require a second look. Both genders are often related to death anxiety. Females tend to report higher death anxiety than males. Although women tend to report higher levels of death-related anxiety, it is also women who provide most of the professional and volunteer services to terminally ill people and their families, and, again, it is mostly women who enroll in death education courses. Women are more open to death-related thoughts and feelings, and men are somewhat more concerned about keeping these thoughts and feelings in check. The relatively higher level of reported death anxiety among women perhaps contributes to empathy with dying and grieving people and the desire to help them cope with their ordeals (Peters et al., 2013).

The greater concern about death reported by women may stem from the fact that they are most often the primary caretakers for the dying. Another explanation for gender differences in death anxiety invokes the concept of locus of control. In study of Sadowski, Davis, and Loftus-Vergari (1979), women were both more concerned about death and more externally controlled.

Findings of Suhail and Akram (2002), Tang et al. (2002), Abdel-Khalek (2005), Lester et al. (2007), Amjad (2014), and Ron (2016) indicated that women showed more death anxiety than men. In study of Abdel-Khalek (2005), there were statistically significant gender differences on the ASDA in which females attained higher mean scores than their male counterparts in the three categories: Egyptian normal participants (nonclinical), anxiety disorder patients, and patients suffering from schizophrenia as well as the total group of males versus females. Abdel-Khalek (2007) declared that relationship between love of life and death distress scales was not significant, except death depression and one pertaining to love of life that was negative in women. Chuin and Choo (2010) reported that women had lower death anxiety. Women tended to report somewhat higher levels of death-related anxiety (Christin, 2011; cited in Scalpello Hammett, 2012). Women possessed higher levels of death anxiety. Social desirability related to gender may influence death anxiety. Females are considered more emotional and empathic (Scalpello Hammett, 2012).

Ali Akbari Dehkordi, Oraki, and Barghi Irani (2011) found that the internal religious orientation negatively and the external religious orientation positively have predicted death anxiety in males and females. Azaiza et al. (2011) showed that bereaved elderly Israeli mothers had higher death anxiety than bereaved elderly Israeli fathers, and religiosity was not related to death and dying anxiety. Mansurnejad and Kajbaf (2012) reported that there was a significant relationship between gender and death anxiety, and death anxiety in the females was higher than in the males. Thabet, Tawahina, Sarraj, and Vostanis (2013) indicated that on the ASDA, mean death anxiety in Palestinians female victims of war on Gaza was statistically significantly higher when compared with male. On the Reasons for Death Fear Scale, Aflakseir (2014) found that there were no differences in four components of the scale including Fear of Pain and Punishment, Religious Transgression, Fear of Losing Worldly Involvements, and Parting from Loved Ones between male and female college students. This result is similar to the finding of Abdel-Khalek (2002), who reported that no gender differences were detected with Arabic and Muslim college students. On the DAS, DDS, and DOS, Bahrami et al. (2014) showed that Iranian women older adults showed higher death distress than men older adults, but the difference was not statistically significant. On the DAS, Ziapour, Dusti, and Abbasi Asfajir (2014) reported that there was a difference between the death anxiety in males and females, and female staff of hospital had more death anxiety than the male staff.

Our findings showed that there were significant associations between age, sex, and death anxiety total score. Lester (1985) indicated that sex and masculinity/femininity scores had little relationship with attitudes toward death. In addition, sex did not account for the relationship between masculinity/femininity scores and attitudes toward death. Scalpello Hammett (2012) reported that death anxiety and age are negatively correlated; however, it is sustained that the influencing factor is psychosocial maturity rather than age. Our results are not similar to previous studies on the samples of middle-aged and the elderly population (e.g., Anuja & Neelakandan, 2014; Scalpello Hammett, 2012; Sridevi & Swathi, 2014). These nonsimilarities can justify to different populations, religions, cultures, and tools in previous studies.

Limitations of the study include use of a self-report scale, selection of a nongeneral population, a nonclinical sample, a Muslim religion, and an Iranian culture. Present results can be considered for psychological therapies for reducing of death anxiety, pathways to death acceptance such as life review, self-acceptance, religious/spiritual beliefs, embracing one’s own life, and death education in Iranian people and also for carrying out cross-cultural studies in other Asian, Arabic, Eastern, and Western countries with shared and nonshared religions and cultures in future studies.

Footnotes

Declaration of Conflicting Interests

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

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Mahboubeh Dadfar has a PhD in clinical psychology and Master of Public Health (MPH) in mental health from Iran University of Medical Sciences. She is interested in research in the fields of clinical psychology, positive psychology, personality psychology, psychotherapy, psychometric properties of psychological tests, mental health, and issues relevant to death and dying. She has published many papers and books. She is a reviewer for some American established scholarly journals.

David Lester has a PhD (Brandeis University) in psychology and a PhD (Cambridge University) in social and political science. He is a distinguished professor emeritus at Stockton University, New Jersey, USA. He founded the Psychology and Criminal Justice programs at Stockton University. He has taught courses on abnormal psychology, personality, psychological testing, and theories of counseling. Lester has been involved in suicidology since 1964 and was elected President of the International Association for Suicide Prevention (IASP). Lester is a leading expert on telephone counseling and has co-editing three editions of Crisis Intervention and Counseling by Telephone most recently with James Rogers. Lester is known as one of the most prolific psychologists in the world for his publication record of more than 2,650 notes, articles and chapters and more than 100 books. He has collaborated with fellow experts from Austria to Zimbabwe. His research has been published in at least 158 American journals and 47 foreign journals, with 74 colleagues in 34 countries. The Stockton University opened the David Lester Lending Library in his honor in 2015.

Ahmed M. Abdel-Khalek has a PhD in psychology. He is a professor at Alexandria University, Egypt. He is interested in research in death anxiety, death obsession, mental health, positive psychology, abnormal psychology, personality psychology, health psychology, and mental health and coined the term and scale of love of life.

Pnina Ron is a gerontologist, a staff member in the School of Social Work, the head of the Pre-Academic-Unit and the head of the English for Academic purposes in the University of Haifa, Israel. Dr. Ron interest in intergenerational transmission and the mental health of the elderly and their family member and, investigating both the Jewish and the Arab population in the state of Israel.

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