"Doctor, Doctor shall I die?
Yes my child, and so shall I."
(in Parkes, Laungani, & Young, 1997, p. 7)
The modern medical sciences, in recent years, have raised the hope of adding years and extending the end of life. Population figures show that the life expectancy in many countries is up to a level that was unheard of in former times. However, though the quality of life and its longevity can be increased, the facts remain that dying and death are inevitable.
Rosenblatt (1997) identified that many communities and societies in developed or developing countries, in various cultures, had created their own pattern to deal with death and dying. How people have accepted the inevitable and unavoidable circumstances of eventual death was discussed by Tony Walter (1997). His presentation compared humanism and secularization, which are concerned more about living and life than about the process of dying and death.
Emotional expression and attitudes toward living and dying are the focus of the present programmatic cross-cultural and international investigations. Attitudes in general, but especially attitudes toward living and dying, may change over the years. Lemme (1995) reported that "Americans now deal with death the way the Victorians dealt with sex. We simply do not like to acknowledge that it goes on" (p. 435). However, there are changes that may occur during different stages of the life span. Kastenbaum (1992) found that most people (i.e., people in the USA) did not seem to face death, but showed only a low to moderate concern about death and dying in their daily routines. This could mean that the general population harbored only a low degree of death anxiety. Dividing the gender data for analyses, the results of death anxiety tests showed that women's scores were higher than those by men (Lonetto & Templer, 1986). These findings were open to speculative interpretations, which could mean, for example, that because of women's greater involvement in providing care and help to people in need, they may be more aware of the possibilities leading to death (Lemme, 1995).
During the last few decades the topic of death and dying has become more prominent. An interesting, but also obvious, fact was found with regard to age: As expected, the evidence showed that there occurred more discussions and thoughts about death with increasing years throughout the life span.
Whereas reports such as those mentioned so far have involved only research in the United States of America, one in-vestigation focused on the multicultural background of the participants. Kalish and Reynolds (1977) studied four populations living in Los Angeles, California: African Americans, Anglo Americans, Japanese Americans, and Mexican Americans. Although their socioeconomic background may have affected their approaches toward death-related issues, the authors found many differences in their death-related attitudes. Kalish and Reynolds reported that the Anglo American population perceived the Mexican American group as very emotional with regard to their attitudes toward death-related issues. On the other hand, the Mexican American participants thought that the attitudes of the Anglo American population were cold in response to death-related topics.
It is, of course, obvious that cultural values, norms, and beliefs influence the attitudes and behaviors of people who are enculturated in different environments. Therefore it is important to conduct specific cross-cultural research with populations who live in different ecologies. Comparing varieties of cultural groups provides answers about cross-cultural differences and similarities. "For example, the present scientific literature is much more likely to report differences rather than similarities between nations or cultures studied. On the other hand, cross-cultural research recognizes that while the discoveries of differences may be significant, the findings of similarities may provide even more meaningful information. Because of the ever-increasing spread of Western culture special emphasis should be placed on such aspects" (Adler, 1977, p. 1).
The Start of a Programmatic Cross-Cultural Study
The current programmatic study started as a cross-cultural investigation of four countries. However, in due time other countries were added. It is like a concert, where several musical pieces are presented to make an interesting program. The same principle occurs in "programmatic" studies.
Originally this study started to analyze data from the USA, Sri Lanka, South Korea, and Kuwait, but one by one more countries were added. At present the study includes six countries, and data from the seventh country are expected.
For many years the basis for cross-cultural research was the comparison of people's behavior as they lived within their different cultural environments. However, this approach either ignored or overlooked many important variables. Much more intensive research on cross-cultural issues is needed. For example, an anecdote might describe differences in attitudes more succinctly. While discussing the topic of death and dying at a meeting in New York City, a young Asian Indian woman, who had been listening, responded spontaneously: "I do not know why there is such a fuss about death and dying; when you die you are reincarnated." Of course the Western response would be: "I never thought of it in such terms."
Due to variations in upbringing and varieties of cultural backgrounds, people's thoughts and attitudes take on different directions. Therefore it is necessary when pursuing cross-cultural research to include many more actions and interactions that shape people's orientation and influence their behavior and lifestyles.
The Beginning of a New Study: "The Overture" (Four Countries)
This research was conducted to investigate attitudes toward living and dying in a cross-cultural study. Some years ago TaeLyon Kim (1992) published the results of her research on attitudes toward living and dying, with Korean American senior citizens as participants. The first investigation (of what was to become a programmatic study) was based on and modified from Kim's research. Both experiments used a questionnaire to assess the attitudes of the participants.
Of the 27 questions/statements of the test booklets, only a few items are reported at this time. The first page of the questionnaire asked for demographic information. Fifteen questions offered multiple-choice answers of "yes," "sometimes/rarely," or "no." Ten questions offered five pertinent answers as a choice. Finally, there were two open-ended questions, which needed to be analyzed separately. The beginning included "nonthreatening" items, and the last few questions ended on a pleasant tone. To respond to the entire questionnaire required about 10 to 15 minutes.
Participants from Four Countries
Instead of being a multicultural study, as was the Kalish and Reynolds (1977) study, this research was a cross-cultural investigation.
Four countries, all with different cultural backgrounds, were selected. These included Kuwait (tested during prewar times; n = 160), South Korea (n = 539), Sri Lanka (n = 454), and the United States of America (n = 563). In each of these countries the participants were men and women.
The groups of participants were divided into three age categories: young adults (18 to 33 years), middle age (34 to 59 years), and old age (60 to 85+ years). However, the distribution of the participants in some countries that contributed data did not yield enough ns for three age groups to allow for statistical analyses. The only country with three large age groups was the USA. Because this study was originally projected to test only the elderly, the data for the young-adult and middle-age groups were missing in the Kuwaiti sample, since Kuwait was the first country to participate. Korea was missing data for the middle-age group, and Sri Lanka did not reach a large enough n in the old-age group. Notwithstanding the omission of these subsamples, we evaluated the data by working with percentages.
Results (Four Countries)
The data for specific questions and responses were computer analyzed. Responses to the question, "Are you lonely?" were: "yes," "sometimes," and "no." In the USA, Sri Lanka, and Kuwait the strongest responses were "no" in all three age groups, with men's and women's answers combined. In Korea, however, the largest number of responses were given to "sometimes."
Another query asked: "If you feel like talking is there somebody, either in person or by telephone?" Again the response choices were "yes," "sometimes," and "no." As with the previous question, the answers from all age groups and from both men and women were combined. The results for the USA, Sri Lanka, and Kuwait were mostly an impressive "yes." Yet the responses in Korea were mostly split between "yes" and "sometimes."
The next item was a very timely and penetrating question that asked: "Do you worry about getting a terminal illness?" The choices for answers were: "yes," "rarely," and "no." All responses included both genders and all three age groups. Korea answered with a strong "no." In Sri Lanka the answers were similar to those from Korea. However, the responses were about evenly distributed among the three choices in both Kuwait and the USA.
For the next question the choices for answers were more specific, since this topic explored a very personal attitude, namely: "What would you do if you found out that you had an incurable illness?" There were five answers to choose from: (a) "continue medical treatment," (b) "pray and hope to die quickly," (c) "stop medical treatment," (d) "do nothing--continue present routine," and (e) "enjoy as much of life as possible while I can."
Whereas men's and women's responses were combined, the age groups were analyzed separately. The results from the USA were reminiscent of Kastenbaum's (1992) findings. The majority of the participants wanted to enjoy themselves as long as they could, though with the two older groups replies increased in number to "continue medical treatment." The Sri Lankan participants gave similar responses: the younger group wanted to "enjoy as much of life as possible," whereas the older participants chose to "continue medical treatment." This pattern of responses also seemed to prevail in Kuwait and in South Korea.
Another interesting question inquired: "To whom can you confide your problems?" The responses were selected from the following choices: (a) "spouse," (b) "children," (c) "friends and/or relatives," (d) "clergy," and (e) "nobody."
The results showed that men and women did not exhibit the same attitudes nor similar patterns of behavior. Whereas the young-adult male participants in the USA, Sri Lanka, and in Korea (Kuwait had this age group missing) chose to confide mainly in "friends and/or relatives," the men in the middle-age and old-age groups confided overwhelmingly in their spouses. However, this pattern varied for the female participants. Young women selected "friends and/or relatives" when confiding their problems. Yet elderly women in all four countries turned frequently to their children or "friends and/or relatives," rather than to their spouses. (Adler, Clark, Denmark, Ahmed, et al., 1999; see Figures 1a, 1b, and 1c).
Summary of First Investigation
This cross-cultural research investigated the participants' attitudes that included some important and challenging aspects of living and dying; therefore, some searching questions were asked. The answers, which are reported here, were insightful and revealing. Even though there were great differences among the traditional lifestyles, the religious and cultural backgrounds, as well as the local languages or mother tongues, many similarities in attitudes and behavior existed among the participants from the different parts around the globe (Adler, Clark, Denmark, Ahmed, et al., 1999).
Continuation of the Programmatic Study: Cross-Cultural and International Comparisons of Attitudes Toward Living and Dying
In time the fifth country, Armenia, was added (Adler, Clark, Denmark, Karakashian, et al., 1999).
Background on Armenia and its People
Armenia has been considered by many to be the "cradle of civilization" (Lang, 1970). The Book of Genesis states that Noah's Ark landed on the summit of Mount Ararat, in the very center of Armenia. Also of historical importance, Greater Armenia was on the silk and spice trade routes that connected the East with the West. Furthermore, it was on the Czarist (and later Soviet) expansionist route that extended from the north to the south. In 1921, however, Armenia--weakened and threatened by war, famine, and economic collapse--fell under the Bolshevic powers and soon became a Soviet state. But, it was not only man-made domination and atrocities that had devastated the Armenian people for centuries, but some natural disasters as well. The most recent of these was an earthquake of catastrophic proportions in the Armenian Soviet Socialist Republic in 1988. This earthquake wiped out over 25,000 lives and destroyed towns and villages. Yet the people of Armenia are reconstructing. In 1992, with the dissolution of the Soviet Union, the Republic of Armenia regained its independence. The resulting economic transition--from a totalitarian political system to a Western democracy and free-market economy--continues to this day. This history of man-made and natural disasters as well as economic instabilities has resulted in a dispersion of the Armenian people in the world. The Armenian diaspora totals approximately 3.6 million people, or about half of the total population currently residing in Armenia (reported by Meline Karakashian, 1999).
The Current International Programmatic Study: A Six-Country Perspective
At this time the cross-cultural and international investigation also includes Egypt, the sixth country in this ongoing programmatic research. As in the past, the comparisons include both adult men and women. However, in this investigation there are just two age categories: middle age and old age. Although the actual number of participants is small, the data from Egypt provide a new source of comparisons.
Following the same method used in the other countries, which was based on Kim's (1992) original study of investigating elderly men's and women's attitudes toward living and dying, the same questionnaire was used. All items in the test booklet were translated--and back-translated--for use in the local vernacular. The questionnaires were the same as those described earlier, and all the data were computer analyzed.
The data from middle-aged and elderly participants (34-85+ years) of the previous investigations (Adler, Clark, Denmark, Karakashian, et al., 1999) were added to the current programmatic analysis. The respondent populations included men and women from Armenia (n = 145), Egypt (n = 23), Kuwait (n = 160), South Korea (n = 232), Sri Lanka (n = 232), and the USA (n = 338).
Results and Discussion
Only some pertinent questions are discussed here. Except for the last item, the responses by men and women were combined.
The query, "If you feel like talking is there somebody, either in person or by telephone?" could be answered with "yes," "no," or "sometimes." A strong "yes" was reported by all six participating populations.
The next item asked was: "Do you worry about getting a terminal illness?" This time the choices for the answers were "yes," "rarely," and "no." The results showed that participants from three countries, Armenia, South Korea, and Sri Lanka, answered a decisive "no." However, participants from Egypt, Kuwait, and the USA divided their answers almost equally among the three choices.
Another query asked, "Are you lonely?" and offered three choices for responding: "yes," "no," and "sometimes." Except for South Korea and Armenia, whose first choices were "sometimes," a strong "no" response was in first place with the other four countries.
The next question dealt with a private attitude that may be difficult to discuss: "What would you do if you found out that you had an incurable illness?" The respondents could choose among: (a) "continue medical treatment," (b) "pray and hope to die quickly," (c) "stop medical treatment," (d) "do nothing--continue the present routine," and (e) "enjoy as much of life as possible while I can." About two thirds of all the U.S. participants felt that they wanted to "enjoy as much of life as possible while I can." As mentioned earlier, it was Kastenbaum (1992) who found that most people (i.e., from the U.S.) did not face death. He thought that they had only low to moderate concerns about "death and dying" in their daily routines. However, the first-place answer by participants in Sri Lanka, South Korea, and Kuwait was to "continue medical treatment." The Egyptian participants' top selection was "pray and hope to die quickly," while the Armenians' first choice was "do nothingâ€"continue present routine." This surprising response was most likely due to the political situation. The availability and accessibility of medical care in the new Armenian Republic probably influenced this attitude. The former opportunities for free medical treatment that were previously provided by the Soviet government were no longer offered. Nowadays the available medical services and treatments are expensive. (Karakashian, personal communication).
The next question concerned and compared the answers to the query: "To whom can you confide your problems?" This time the choices for answers were: "spouse," "children," "friends and/or relatives," "clergy," and "nobody." Male and female participants frequently responded differently, therefore the data could not be pooled. Analyzing the first and most frequent choice by middle-aged and elderly men was "spouse," for all countries except Armenia, where the top choice was "children," yet "spouse" followed closely behind. In other words, the responses by men from the six different countries were rather uniform. That was not the case for the women. "Spouse" was in first place only in Sri Lanka. In Armenia this response was tied for first place with "children," which was the top answer in Egypt and Kuwait, while "friends and/or relatives" held the first place in South Korea and the USA (see Figures 2a, 2b, and 2c).
Though the Armenian participants, both men and women, selected "children" and "spouse" as their first and second choices, both sexes responded with "nobody" in the third place. It was surprising to get such a response. This answer from the Armenian participants revealed an important connection, not to traditional situations, but ties to recent and political conditions. Meline Karakashian offered several suggestions to explain this choice. "People lack trust in others, save for spouse and children, in this formerly Soviet country. In addition, it may be to avoid the spread of rumors in this close-knit Armenian community which may have led to the response of "nobody" (personal communication, 1999).
The same question brought out another interesting and meaningful choice of answers. The men mainly confided their problems to their spouses (see Figure 2a). The women, on the other hand, confided mostly to their children and to "friends and/or relatives" (see Figures 2b and 2c). Only the Sri Lankan female participants and the Armenian women, who tied their responses with "children," selected to confide in their spouses. Considering that traditionally women were usually dependent on their husbands for their physical and intellectual well-being, these cross-cultural responses were surprising and unexpected. It may have been that the men's retirement from their jobs, or widowhood, or the recently changing lifestyles of women in modern or modernizing societies, could have been among the reasons for the given responses, rather than the traditional and cultural background.
In closing, it is well to point out the remarkable and signifi-cant results and findings concerning the obvious similarities of the responses by different populations, even though the participants' religions, languages, and cultural and ecological backgrounds were different.
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Authors' note. The authors want to express their appreciation to Dr. Beverly S. Adler-Gross for her assistance and support with this cross-cultural and international programmatic study. Also, to Mr. Gerald Knobelauch for processing the data for this programmatic research, to Ms. Patricia Shin for translating the South Korean data, to Mrs. Sheila Perera for translating the Sri Lankan data, to Ms. Diana Antabian for translating the Armenian data, and to Mr. Kenneth Gruenfeld for categorizing the Egyptian data: many thanks are extended to each.