Factors Associated with Death Literacy Among Older Persons with Multimorbidity

Abstract

Introduction Multimorbidity is highly prevalent in older persons and is associated with increased mortality. At the end of life, older persons who lack adequate preparation often experience a poor quality of death. Death literacy is defined as the knowledge and skills necessary to access, understand, and make informed decisions about end of life and death care. Factors influencing death literacy include six domains: attitudes toward death, attitudes toward end-of-life care, death anxiety, religious beliefs, religious practices, and social support.

Objective This study aimed to examine the relationships of attitudes toward death, attitudes toward end-of-life care, death anxiety, religious beliefs, religious practices, social support and death literacy among older persons with multimorbidity. 

Design This study employed a correlational descriptive design, drawing upon the concept of death literacy, which extends from the framework of health literacy proposed by Sorensen and colleagues. Health literacy is defined as encompassing knowledge, competencies or abilities, and motivation, with three principal determinants: personal, situational, and societal and environmental determinants. Guided by this framework, this study selected factors hypothesized to be associated with death literacy, including death anxiety, attitudes toward death, attitudes toward end-of-life care, religious beliefs, religious practices, and social support. 

Methodology The sample consisted of 240 participants aged 60 years and above, each diagnosed with at least two chronic diseases, cognitively intact, adherent to Buddhism, able to communicate in Thai, and willing to participate in this study. Multistage sampling was used. First, Mueang District in Chiang Mai Province was selected; then, one subdistrict was randomly selected based on geographic criteria. Participants were recruited from each subdistrict using proportionate random sampling among those who voluntarily enrolled. Data were collected using the following instruments: the Death Literacy Index, Death Attitude Profile - Revised (DAP-R), Frommelt Attitude Toward the Care of Dying, the Religious Belief Scale, the Religious Practices Scale, and the Social Support Scale. All instruments underwent content validity assessment. The Thai-translated versions of the Attitudes Toward Death Scale and Death Literacy Scale demonstrated content validity indices exceeding .80. Reliability testing indicated Cronbach’s alpha coefficients greater than .80 for all measures. Data were analyzed using descriptive statistics and Pearson’s correlation. 

Results The mean score of death literacy was 7.77 (SD = 1.05) out of a maximum of 10. Attitudes toward death, death anxiety, religious beliefs, religious practices, and social support were at moderate levels, while attitudes toward end-of-life care were positive. Attitudes toward end-of-life care, attitudes toward death, and social support showed positive correlations with death literacy at a low level (p < .05; r = .126, .133, and .133, respectively). Religious practices demonstrated a positive correlation with death literacy at a low level (p < .01; r = .193). While death anxiety and religious beliefs were negatively correlated with death literacy at a low level (p < .01; r = –.181 and –.194, respectively). 

Recommendation The results of this study suggest approaches to promote death literacy among older persons with multimorbidity by focusing on fostering positive attitudes toward death and end-of-life care, reducing death anxiety, and enhancing social support and engagement in religious practices.