methodology

A Cross Sectional Study of the Relationship between Death Attitudes and End of Life Planning in Nairobi County, Kenya Presented by Asatsa Stephen at the International Society for the Study of Behavioral Development (ISSBD) Biennial meeting, Gold Coast Australia July 15-19 2018. Email: [email protected]

BACKGROUND

Preparation for own death remains a neglected part in the human life span. = Most countries invest heavily in death prevention with little or no policies on death preparation.

= Several studies relate death preparedness to quality dying (Munn JC, Zimmerman S, Hanson LC, et al.2007 )

= Hospice and palliative care is the emerging model of death preparation in many countries.

= Kenya faces several challenges related to end of life planning Most people die intestate

= World Palliative Care Alliance (WPCA) estimates the number of people in need of palliative care to be 20.4 million 94% of which are adults.

= The value of unclaimed assets continues to rise and stands at $ 2 million as at 2015

= A large percentage of them (78%) live in low income countries (WPCA,2014)

= Post death family conflicts are on the rise

= Kenya's total population of 40 million is served by 65 palliative care centers.

= Studies on death in Kenya have focused on grief, mourning and bereavement (Asatsa,

= Focus is on the terminally ill leaving out the larger population of those dying from home.

= Muola& Mwania, 2014, Ndungu, 2007 and Afandi, 2011).

= Much emphasis on medical aspects of patients leaving out the psychological.

= Current study deviates from this and focuses on one's response to own death.

METHODOLOGY Research Design: Mixed methods sequential explanatory design. Data Collected in two phases, quantitative model dominant. Target Population: The study targeted adults aged at least 20yrs Sampling Multistage Sampling

Clustered Sampling

Age 20 - 34 35 - 64 65 and above

1 institution per Sub County

5 Religions

5 Sub Counties

Nairobi county 16 sub counties

Stratified Sampling

Protestants Catholics Muslims Hindus Traditionalists Atheists

Proportionate Selection of participants

QUAN 320 Extreme Case Sampling QUAL 20

Instruments Interview Guide

End of life Pertinent Issues Questionnaire (24 item ) - Measures end of life planning on 4 domains: Spiritual planning, Estate planning, Funeral planning, Personal Disclosure - Internal Consistency showed x =0.78 - Scores ranged from 0 to 5.

Death altitudes Profile - Revised (32 items) - Measures death altitudes on 5 domains Fear of death; Death avoidance; Approach acceptance; escape acceptance; Neutral acceptance. - Confirmatory factor analysis done and confirmed the 5 domains - Internal consistency showed x = 0.85 - Score ranged from 0 to 7.

Demographic differences in death attitudes and end of life planning Neutral Acceptance

5.50

Fear of Death

5.00

Death Avoidance

Approach Acceptance

4.50 4.00

Escape Acceptance

3.50 US$ 501-1000

20 - 34 years

US$ 1000 and over

Participant Income Level

Fear of Death Death Avoidance Catholic

Muslim

Hindu

Traditionalist

Atheist

Religious Affiliation of Participants

US $ 501 - 1000

Approach Acceptance

4.00

Escape Acceptance US$ 0 - 100

Mean

Approach Acceptance

4.50

Escape Acceptance

3.50 Married

Divorced

Single

Widowed

Marital status of Participant

Married

Divorced

Spiritual Planning Estate Planning Funeral Planning Personal Disclosure US $ 101 - 500

US $ 501 - 1000

US $ 1000 and over

Spiritual Planning Estate Planning Funeral Planning Personal Disclosure Single

Widowed

Married

Divorced

Widowed

Marital status of Participant

Figure 13: Marital status differences in end of life planning

Figure 9: Marital status differences in positive death attitudes

Death Attitude and end of life planning

Demographic factors and end of life planning

Spiritual Planning

End of life planning

Demographic factors

Traditionalist Atheist

4.50 4.00 3.50 3.00 2.50 2.00 1.50

Marital status of Participant

Figure 5: Marital status differences in negative death attitudes

Hindu

Figure 12: Income level differences in end of life planning Neutral Acceptance

4.00

3.00

Muslim

Participants Income Level

5.00

3.50 Single

Personal Disclosure

US $ 0 - 100

US$1000 & above

5.50

Death Avoidance

4.60

Funeral Planning

4.50 4.00 3.50 3.00 2.50 2.00 1.50

Figure 8: Income level differences in positive death attitudes Fear of Death

4.50

US$501 - 1000

Estate Planning

Participant Income Level

Figure 4: Income level differences in negative death attitudes

5.00

US$ 101 - 500

Spiritual Planning

Figure 11: Religious differences in end of life pertinent issues Neutral Acceptance

5.00

US $ 1000 and over

65 years and over

Religion affiliation of participants

Mean

US $ 101 - 500

35 - 64 years

Protestants Catholic

3.00 Participant Income Level

Mean

Catholic Muslim Hindu Traditionalist Atheist Religion Affiliation of participant

6.00

Death Avoidance US $ 0 - 100

Marital Status

Escape Acceptance

7.00

Fear of Death Mean

Mean

Income

5.00 4.50 4.00 3.50 3.00 2.50 2.00

Personal Disclosure

4.50 4.00 3.50 3.00 2.50 2.00 1.50

Figure 7: Religious differences in positive death attitudes

Figure 3: Religious differences in negative death attitudes

Funeral Planning

Figure 10: Age differences in end of life planning

Approach Acceptance

Protestant

Estate Planning

Age of Participant Neutral Acceptance

7.00 6.00 5.00 4.00 3.00 2.00 1.00

Spiritual Planning

20 - 34 years

Figure 6: Age differences in positive death attitudes

Mean

Mean

5.00 4.80 4.60 4.40 4.20 4.00 3.80 3.60

4.50 4.00 3.50 3.00 2.50 2.00 1.50

65 years and above

Age of Participant

Figure 2: Age differences in negative death attitudes

Protestant

35 - 64 years

Mean

US$ 101 - 500

Mean

US $ 0 - 100

Religion

Mean

5.00 4.50 4.00 3.50 3.00 2.50 2.00

Estate Planning Funeral Planning

Personal Disclosure

2

(R = 0.197 F = 18.74 P = 0.000) 2

(R = 0.283 F = 29.87 P = 0.000)

Inferential Analysis (Multiple regression)

Death Attitudes

2

(R = 0.148 F = 18.74 P = 0.000)

End of life planning

Age

End of life Planning

Positve Death Attitude

Mean

Mean

Negative Death Attitude

2

Spiritual Planning

(R2 = 0.475 F = 18.74 P = 0.000)

Estate Planning

(R2 = 0.309 F = 35.38 P = 0.000)

Funeral Planning

(R2 = 0.73 F = 4.76 P = 0.000) (R2 = 0.228 F = 29.58 P = 0.000)

Personal Disclosure

(R = 0.228 F = 29.58 P = 0.000)

Rationale for death attitudes and end of life planning Table 4: Rationale for positive death attitudes

Table 3: Rationale for negative death attitudes Themes

Unfulfilled life goals Dying process is threatening Family attachment Unresolved family conflicts Families with young children Fear of hell Finality of death (Permanency) Unresolved past deaths

Themes

Frequency (%) 20 - 34 Years 70% 55% 40% 10% 5% 20% 30% 60%

35 - 64 Years 25% 35% 50% 60% 80% 40% 45% 30%

65 years and above 5% 10% 10% 30% 15% 40% 25% 10%

Reuniting with deceased pears and relatives Meeting the creator Fulfilled past life Prolonged miserable life Lack of death awareness Transformation after death Feeling of alienation

Frequency (%) 20 - 34 Years 5% 30% 10% 10% 60% 10% 5%

35 - 64 Years 15% 40% 20% 45% 25% 30% 15%

CONCLUSION = Demographic factors (Age, monthly income, marital status, Religion) were found to be significant predictors of end of life planning. = Death attitudes were found to be significant predictors of end of life planning. = The study recommends death education to create awareness

= Family cohesion is important in promoting end of life planning. = Religious belief could be harnessed to enhance positive death attitudes. = counseling could help integrate past unfulfilled life with the present life to facilitate quality dying.

65 years and above 80% 30% 70% 45% 15% 60% 80%

Table 5: Rationale for low end of life planning Themes

Frequency (%)

Lack of death awareness Cultural factors Planning for death is welcoming it Attachment to property Irresponsible heirs Mistrust among family members Religion

20 - 34 Years 55% 15% 35% 10% 5% 5% 20%

ACKNOWLEDGEMENT = ISSBD for funding this study = Dr. Sabina Mutisya and Dr. Bethwell Owuor

35 - 64 65 years Years and above 35% 10% 35% 50% 35% 30% 55% 35% 15% 80% 60% 35% 40% 40%

ISSBD Mentors = Dr. Anne Petersen (Michigan University) = Dr. Suman Verma (Punjab University)