The effect of death education on fear of death amongst Italian adolescents: A nonrandomized controlled study

Evaluation of a knowledge-attitude-practice model based narrative life education program for community-dwelling older adults: a mixed-methods feasibility study

BACKGROUND

The global aging population presents challenges that are particularly acute in China. Older Chinese adults' attitudes towards death significantly impact their quality of life. Death education is crucial for promoting positive perspectives on life and death. Narrative education offers a promising approach to facilitating death education. Integrating the Knowledge-Attitude-Practice (KAP) model into death education will enhance the feasibility and acceptability of death education programs.

METHODS

This mixed-methods feasibility study included a quasi-experimental trial and semi-structured interviews. Older adults in the intervention group (N = 27) received a 6-week KAP-based narrative life education program in addition to standard community health education; participants in the control group (N = 20) received only the normal community health education. In both groups, attitudes toward death and the meaning of life were assessed at baseline and immediately after the intervention. A post-intervention semi-structured interview and satisfaction survey were also conducted for the intervention group.

RESULTS

Forty out of 47 older adults completed the program for an 85.1% retention rate. All of the older adults in the experiment were very satisfied and satisfied with the life education program, and no adverse events were reported. Compared to the control group, participants in the intervention group had a significant decrease in the fear of death (P = 0.028), and substantial improvement in their value of life (P = 0.031), goal of life (P = 0.035), freedom of life (P = 0.003), and the total score for purpose in life (P = 0.017). The qualitative results yielded four themes: profound recognition of life and death, contradiction between thoughts and action, conflict between one's acceptance and others' avoidance, and evaluation of the life education program.

CONCLUSIONS

The KAP-based narrative life education program is feasible and acceptable for older Chinese community-dwelling adults. It is also potentially effective in improving attitudes toward death attitudes and the meaning of life in this cohort.

TRIAL REGISTRATION

This study was retrospectively registered at China Clinical Trial Registry as ChiCTR2300069551 on 2023-03-20. URL of registration: https://www.chictr.org.cn/showproj.html?proj=183176 .

Death in the Scottish curriculum: Denying or confronting?

The important role of schools in supporting children experiencing bereavement is established, yet less is known about how school curricula include death as part of life and this limits our understanding of the systemic structures that shape children's knowledge and experience of death. To address this gap, this paper discusses an analysis of the Scottish curriculum to explore the extent to which death features in compulsory education for children aged 3 to 15 years. The findings show that whilst death is present across the curricula, certain types of 'knowing' death are promoted, largely situated across religious teaching, which may limit children's engagement with the multiple and complex ways in which death features across individual, social, physical, and relational domains. By integrating the concepts of death systems and death ambivalence, the paper develops new knowledge on the interplay between curricula and sense making around death in children's lives that has practical utility.

Eudaimonic Well-Being of Italian Young Adults during the COVID-19 Pandemic: Predictive and Mediating Roles of Fear of Death and Psychological Inflexibility

The literature has widely acknowledged the impact of the COVID-19 pandemic on the mental health of young adults. Despite extensive research, eudaimonic well-being, which focuses on self-knowledge and self-realization, has been scarcely investigated. This cross-sectional study aimed to add knowledge on the eudaimonic well-being of young adults one year after the outbreak of the COVID-19 pandemic, verifying its potential linkages with fear of death and psychological inflexibility. A total of 317 young Italian adults (18-34 years), recruited through a chain sampling method, completed measures of psychological inflexibility, fear of death, and eudaimonic well-being included in an online survey. The study's hypotheses were tested with multivariate multiple regression and mediational analyses. Results showed that psychological inflexibility was negatively associated with all the dimensions of well-being, while fear of the death of others was associated with autonomy, environmental mastery, and self-acceptance. Furthermore, in the association between fear of death and well-being, the mediation role of psychological inflexibility was verified. These results contribute to the extant literature on the factors associated with eudaimonic well-being, providing clinical insights into the work with young adults within challenging times.

Death education for Palliative care: a european project for University students

BACKGROUND

The need to spread the culture of palliative care and to train health care professionals from undergraduate courses is recognised internationally. The article presents the outcomes of a project devoted to palliative care training in university courses in four countries.

AIMS

This article considered the outcomes of a course designed for university students who had the potential to work in a palliative care team. The main aim was to check the efficacy of the course and the motivation to work in palliative care settings, considering the impact of fear and representations of death.

METHODS

The project presented the essential contents related to palliative care, using psychodramatic and photo-voice techniques. Longitudinal measurements were taken using a quantitative method design to detect changes among the students involved. The project involved 341 students at the first administration of the survey consisted of a protocol composed of standardized questionnaires in five countries (Austria, Israel, Italy, Poland and Romania), of whom 276 completed the pre- and post-surveys-165 of them in the experimental group and 111, in the control group.

RESULTS

The experience showed that it is possible to address death-related issues seriously and competently without necessarily causing discomfort and despondency in students. The results of the changes over time in the experimental and control groups highlight how the view of death as annihilation is correlated with the fear of death and the need for avoidance of thoughts concerning dying. The main result is that competence in palliative care facilitates familiarisation with issues of death and dying, as well as the ability to work in this area, thereby enhancing interpersonal skills.

CONCLUSION

The project showed that it is possible to implement death education on palliative care topics in undergraduate courses to increase motivation to work in this field.

Interest and Confidence in Death Education and Palliative Psychology in Italian and Indian University Students of Psychology: Similarities and Differences

Teaching death education and palliative psychology in universities has proven to be of great importance, especially in the health professions. The present study aims to evaluate the similarities and differences in interest and confidence in death education and palliative psychology between university psychology students from two culturally different countries: Italy and India. For this study, 63 Italian and 35 Indian psychology students were recruited to take part in a course on death education and palliative psychology. The results showed the positive impact of a death education and palliative psychology course on the training of professionals. In particular, this course was useful in helping students become familiar with and learn how to manage future professional situations related to death and dying. Specific differences between the two countries also emerged, particularly with regard to their approach to the end-of-life field, due to different cultural contexts. There is still much to be done by institutions to improve the dissemination and academic teaching of this area, which in turn can promote job opportunities for young people and encourage them to work in this field.

Italian Children's Accounts of the Lockdown: Insights and Perspectives

COVID-19 lockdown-imposed restrictions emerged as a risk to children's well-being. However, the extant literature often ignored children's experiences, emotions, struggles, hopes, and expectations. Based on a large sample of Italian students (N = 906; mean age = 9.4 years, 48.8% female), we drew data from a post-lockdown school re-entry program where students completed narrative activities in 2020. These narratives underwent quantitative content analysis according to gender and school level. Overall, children reported mixed feelings about the lockdown; they felt safe at home but also experienced fear and missed their friends, school, and freedom. Screen-time, technology and friendships helped, but children struggled to make sense of the events. Our findings show how children attempted to make sense of the lockdown experience and may provide key information for the development of community coping programs to help children facing crises in the future.

Applying terror management theory as a framework to understand the impact of heightened mortality salience on children, adolescents, and their parents: A systematic review

Terror Management Theory (TMT) posits that controlling death anxiety is a driving force behind many aspects of social behavior. The objective in this systematic review was to explore how TMT is used to explain children's, adolescents', and parents' behavior when exposed to situations that increase mortality salience. A systematic search identified 2484 papers; 14 studies met eligibility criteria. Key topics explored were mortality salience, death thoughts, and distal defenses. Findings indicate that adolescents comprehend death and have mortality salience reactions like adults, highlighting the potential for TMT to be used to explain children's and adolescents' social behavior in high-stress situations.

The Central Role of Schools in Promoting Death Education Interventions

Avoidance of discussion about death is common in contemporary Western societies. Plenty of literature substantiates that (at the beginning of the sentence), the actual tendency toward death denial can produce many negative effects such as the suppression of death-related thoughts and emotions. Death Education aims to strengthen the psychological anchors that allow us to recognize the profiles of anguish, prevent the decompensating factors of pathological mourning and process the experiences of loss at all ages. The article aims to support the usefulness and use of Death Education interventions in schools and their central role in promoting these interventions.

Comparison of the level of Fear of Death among Nursing and Pedagogy students

OBJECTIVE

To compare the level of Fear of Death among students of Nursing and Pedagogy courses.

METHOD

A cross-sectional study of a quantitative approach developed with university students from two courses, one around health sciences and the other around human sciences. A random sampling was adopted, calculations based on the principle of power analysis and the 95% confidence interval, and the cutoff point at 100 in relation to the overall score of the Collett-Lester Death Fear Scale for analysis of variables after the application of the Scale.

RESULTS

The data present that the related variables of gender, age, presence of children and loss of a loved one, showed an association with greater Fear of Death in both groups, with statistical significance for most dimensions of the EMMCL. The women presented a higher score in the four dimensions of the EMMCL for both groups. A statistically significant strong negative correlation was identified between age and the level of Fear of Death.

CONCLUSION

It is important to create areas in undergraduate courses, whether around health sciences or humanities, enabling a discussion on Thanatology, so that students have some preparation in dealing with issues associated with the greatest Fear of Death and to view it as a natural process and relevant to everyone. Thus, in their professional practice, it will assist to minimize the emotional suffering of patients and family members.

A Death and Dying Class Benefits Life and Living: Evidence From a Nonrandomized Controlled Study

Humanistic theorists have long emphasized the importance and benefits of death awareness (Yalom, 1980) yet the literature on death education has focused on fear and anxiety. In the present study, 150 undergraduate students taking either a class on death and dying or a comparison class completed a pre and post-questionnaire on attitudes (negative and positive), values (intrinsic and extrinsic) and eudaimonic wellbeing (meaning in life and vitality). Results revealed that compared to their peers in another class, students studying death and dying significantly increased in death acceptance, intrinsic values, meaning in life, and vitality. Furthermore, increases in intrinsic values mediated the relationship between participation in death and dying education and meaning in life. Results are discussed in light of experiential learning, posttraumatic growth, and terror management.

The experience of children with a parent suffering from Amyotrophic Lateral Sclerosis during the COVID-19 pandemic

Children that have a parent with Amyotrophic Lateral Sclerosis (ALS) suffer from the progressive loss of their beloved ones. During the COVID-19 pandemic, the difficulties faced by these children have increased. The study aimed to detect whether there were differences between the minors experiencing a relative's ALS and the minors with no experience of ALS and it aimed also to detect the impact of COVID-19 pandemic on these minors. The study involved Italian participants, in particular: the target group consisted of 38 children (7-18 years) (T0/T1); the control group consisted of 38 children (9-14 years) (T0 only). The following variables were measured: attachment with the Security Scale (SS), affects with the Positive and Negative Affect Schedule for Children (PANAS-C), behavioural problems with Strengths and Difficulties Questionnaire (SDQ), death representation with Testoni Death Representation Scale for Children (TDRS-C), self-concept with the Multidimensional Self Concept Scale (MSCS), resilience and socio-emotional skills with the Devereux Student Strengths Assessment (DESSA). The results showed higher negative affectivity (p < .001), externalising behaviours (p < .05), uncertainty in reflective function (p < .05) in the target group compared to the control one; after the COVID-19 pandemic minors in the target group showed reduced certainty of mental states (p < .05) and interpersonal and scholastic self-esteem (p < .05). The impact of ALS on these minors is significant and produces negative affect, externalizing behaviours and uncertainty of mental states. The lockdown situation due to the COVID-19 pandemic has further aggravated minors in their school and interpersonal self-esteem.

The presence of death in Spanish education law (1812-2006)

The objective of this study is to determine whether death has been present, and if so in what way, in Spanish education law from 1812 to 2006. The presence of 25 terms semantically related to death was analyzed in laws and regulations on school curricula. Death is generally absent as a directly approachable phenomenon within the given period, except in scattered regulations which, as a rule, link death in education to religion. From the beginnings of the democratic period in Spain (1975), socially relevant subjects with indirect but significant relationships with death, such as biodiversity and the Holocaust, appear.

Psychology Students' Perceptions of COVID-19 in a Death Education Course

The systematic removal of death from social life in the West has exposed people living in areas affected by COVID-19 to the risk of being unable to adequately manage the anxiety caused by mortality salience. Death education is a type of intervention that helps people manage their fear of death by offering them effective strategies to deal with loss and anxiety. To that end, a path of death education has been carried out with University students of psychology. The main purpose of the research is to understand how students who participated in the death education course perceive the lockdown experience in light of course teachings. The research was carried out at a University in northern Italy in an area severely affected by COVID-19, during the first year of the pandemic. The group of participants included 38 students, 30 women and 8 men, with an average age of 25.45 years (SD = 7). At the end of the course, the students could respond on an optional basis to the request to comment on the training experience according to what they experienced during the pandemic. A thematic analysis was subsequently carried out on the texts, which made it possible to identify the most relevant thematic areas for the students. The qualitative analyses permitted recognition of three main forms of discovery: the removal of death in contemporary culture; the importance of community, ritual and funeral, and spirituality; and the significance of death education for future health professionals. The texts have highlighted how the removal of these issues exposes people to the risk of being unable to handle extremely painful events such as those related to dying. The results show the positivity of death education pathways conducted at the University level to help students reflect on these issues and manage the related anguish.

The hospice as a learning space: a death education intervention with a group of adolescents

Background

The denial of death in Western society deprives young people of the tools to derive meaning from experiences of death and dying. Literature shows that death education may allow them to become familiar with this topic without causing negative effects. This article describes the effects of a death education course with adolescents, wherein participants were given the opportunity to meet palliative doctors and palliative psychologists at school and in a hospice, where they were able to converse with the families of the dying.

Methods

This study used mixed methods and included an evaluation of a death education intervention with longitudinal follow-up of outcomes. The course involved 87 secondary school students (experimental group) aged between 16 and 20 years. We also recruited a control group of 76 similarly-aged students to observe differences. The variables we examined were: alexithymia, representation of death, value attributed to life and spirituality. These were measured with the following instruments: the Toronto Alexithymia Scale-20, the Testoni Death Representation Scale, the Personal Meaning Profile and the Spiritual Orientation Inventory, respectively. To better understand how the students perceived the experience, we asked the experimental group to answer some open-ended questions. Their answers were analysed through thematic analysis.

Results

The study showed that death education and the hospice experience did not produce negative effects, but rather allowed students to decrease alexithymia, improving their ability to recognise and express emotions. Thematic analysis revealed that all participants perceived the experience as very positive.

Conclusions

Our findings affirm that death education programs can be successfully implemented in high schools, and that they can usefully involve local hospices and palliative care professionals, especially physicians and psychologists.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00747-w.

Students' Confidence and Interest in Palliative and Bereavement Care: A European Study

As part of a European Erasmus Plus project entitled Death Education for Palliative Psychology, this study assessed the ways in which Master's Degree students in psychology and the creative arts therapies self-rated their confidence and interest in death education and palliative and bereavement care. In five countries (Austria, Israel, Italy, Poland, Romania), 344 students completed an online questionnaire, and 37 students were interviewed to better understand their views, interest, and confidence. The results revealed some significant differences between countries, and showed that older respondents with previous experience as formal caregivers for end-of-life clients showed greater interest in obtaining practical clinical competence in these fields. A mediation analysis indicated that students' previous care experiences and past loss experiences were related to students' current interest in death education and palliative and bereavement care through the mediation of their sense of confidence in this field. The qualitative findings identified five shared themes: life and death, learning about death, the psychological burden, personal experience and robust training, and four key training needs. Overall, students' interest in studying and working with terminal illness and death are rooted in internal resources, a preliminary sense of confidence, but also external requirements.

"Imagine You Have ALS": Death Education to Prepare for Advance Treatment Directives

The study presents the results of qualitative research carried out within a death education project dedicated to advance treatment directives (ATDs) in which it was proposed to participants to empathize with people who had received a diagnosis of Amyotrophic Lateral Sclerosis (ALS). The study involved 104 people who discussed and reflected on issues related to the knowledge of having to die, palliative care and ATDs, investigating what choices they would have made if they had received such a diagnosis. Finally, they were asked to write a paper describing their impressions and hypothetical choices. Qualitative analysis has elucidated among fundamental themes. Four thematic areas emerged from the data analysis: (1) ATDs and the family; (2) the importance of reducing pain and suffering; (3) emotions and considerations regarding death, illness and spirituality; and (4) opinions on the DeEd course. It has emerged that some people are unfamiliar with palliative care or the right to self-determination and that addressing these issues helps manage the thought of the future with less terror. The experience of death education has therefore proven to be very positive in dealing with complex and often censored issues, allowing thinking about death in a less distressing way.

The Hospice as a Learning Environment: A Follow-Up Study with a Palliative Care Team

In Western society, the topic of death has been removed from everyday life and replaced with medical language. Such censorship does not reduce individuals’ fear of death, but rather limits their ability to elaborate their experiences of death, thus generating negative effects. The objective of this follow-up qualitative study was to detect how and if death education can help to improve individuals’ relationship with death and enhance care environments like hospices. Semi-structured interviews were conducted with palliative care professionals and teachers who had taken part in a death education initiative three years earlier. The results confirmed the initiative’s positive effect on both palliative care professionals and teachers. The participants reported that the education initiative helped them to positively modify their perspective on death, end-of-life care, and their own relationship to life, as well as their perception of community attitudes towards the hospice, which seemed to become less discriminatory. This study confirmed that school education initiatives can usefully create continuity between hospices and local communities. This project provided an educational space wherein it was possible for participants to elaborate their experiences in relation to death and to re-evaluate and appreciate hospices.

Enhancing Existential Thinking through Death Education: A Qualitative Study among High School Students

The censorship of death-related issues is widespread in contemporary Western culture because the boundary between death and life is substantially managed in medical areas. In the context of Italian educational initiatives, to remove this limitation, 215 high school students in Southern Italy were educated on death through conventional and informal lessons. The students answered a questionnaire with open questions to survey their emotional and reflective experiences. Their answers were qualitatively, thematically analysed to explore how the representation of death can follow a death education course, and if this experience can be managed without harmful effects. The students’ answers narrated how the course reduced their anxiety linked to these themes, on the one hand improving communication between peers by making it more authentic and empathic and, on the other, providing alternative perspectives on life. Indeed, the project offered an opportunity to discuss something strongly heartfelt but rarely faced, and the survey confirmed that the research objectives were fully achieved.

Can Desire and Wellbeing Be Promoted in Adolescents and Young Adults Affected by Cancer? PhotoTherapy as a Mirror That Increases Resilience

PhotoTherapy represents a recent psychotherapeutic intervention which, through the medium of photography, has the objective of helping a patient reach a higher self-knowledge and explore thoughts, desires, and intimate perceptions that would otherwise remain hidden. Because of this, it may help people overcome their cognitive and emotional boundaries and bring out their interiority, even when exploring some of the most distressing themes. The objective of the present research was to demonstrate that the elaboration and expression of inner desires, fears and needs of wellbeing among adolescents and young adults, who were either sick or had been cured of cancer, could be facilitated through the use of PhotoTherapy. Their responses were also compared with those of healthy young adults, in order to be able to explore the kind of impact such a pathology can have on those who are affected by it and highlight eventual differences in the kind of desires and needs expressed instead by those who never had a diagnosis of cancer. A qualitative research design was adopted. 45 people took part in the study, aged between 12 and 25 (mean age 19). The participants were divided into three groups: those currently being treated for cancer, those with a history of cancer and those who had no experience of cancer (third group). From the data analysis, different preferences and attitudes toward the presented pictures and themes emerged among the participants, depending on the specific group they belonged to. The article discusses these preferences and considers how PhotoTherapy can help treat psychological distress caused by cancer.

[Terror awareness of 5th year medical students in the Mannheim reformed curriculum medicine plus]

BACKGROUND

The treatment of gunshot wounds and wounds caused by explosive devices as used in terrorist attacks is not currently an issue for education in most medical faculties; however, because of the increasing number of terrorist attacks in Germany and Europe this is becoming more important. The aim of this study was to evaluate the knowledge of dealing with and treatment of patients as victims of terrorist attacks of 5th year medical students at the Mannheim Medical Faculty of Heidelberg University prior to and after a specific seminar.

METHODS

All students offered to participate voluntarily. Before the seminar a questionnaire with six questions about previous knowledge on terror awareness was distributed. After the seminar another almost identical questionnaire with six questions was distributed and completed by the students.

RESULTS

A total of 97 medical students agreed to take part in the study of whom 53 were female. The mean age was 25.4 years (SD 2.75 years). After the seminar the students wanted to statistically significantly intensify the topic and believed that hospitals should be prepared for the treatment of victims of terrorism.

CONCLUSION

With the seminar "Military Medicine", which was held as part of the Mannheim reformed curriculum of medicine (MaReCuM plus) in the 5th year, the interest of medical students could be significantly increased. This study could show for the first time that terrorist attacks and the resulting injuries have significant relevance for medical students. Consideration of this topic in all medical school curricula would be justified.

Beyond the Wall: Death Education at Middle School as Suicide Prevention

This study investigates the psychological effects of participation in Death Education (DeEd) by middle school children in two towns in northeast Italy in which suicides occur to a greater extent than in the rest of the region. The aims of the project "Beyond the Wall" were inherent to the prevention of suicide, address existential issues and enhance the meaning of life through positive intentions for the future and reflection on mortality. It involved eight classes (150 students in four classes in the experimental group; 81 in four classes in the control group) engaging with films, workgroup activities, photovoice and psychodrama. The constructs of resilience, emotional competency and psychological well-being were monitored with the Resilience Scale for Adolescents, the Hopelessness Scale for Children, the Alexithymia Questionnaire for Children and the Stirling Children's Well-being Scale. The DeEd intervention was found to be significantly related to some of the variables investigated, improving the students' ability to recognise emotions and communicate them verbally while maintaining stable initial characteristics, such as psychological well-being and positive expectations for the future.