EXPLORING THE IMPACT OF SOCIAL FACTORS ON ATTITUDES TOWARD DEATH IN ELDERLY ADULTS IN MALAYSIA'S

Purpose: The purpose of this study was to investigate attitudes toward death among older adults in Malaysia's Klang Valley and to identify the social factors that influence these attitudes. Theoretical framework: The study was based on the theoretical framework that death attitudes can have a significant impact on the physical and mental health of the elderly, as well as on their acceptance of care and quality of death. Method/design/approach : A cross-sectional survey was conducted, involving 165 older adults in Malaysia's Klang Valley. The study used nonparametric tests to investigate the social factors that influence attitudes toward death in the elderly. Results and conclusion: The study found that the various dimensions of death attitudes among older adults in Malaysia are influenced by one or more factors, including the number of illnesses, discussions about life and death, marital status, and income. These findings contribute to expanding knowledge about death attitudes among older adults and provide a reference for understanding attitudes toward death in the elderly. Research implications: The study has important implications for healthcare providers and policy makers who work with older adults, as it highlights the need to consider social factors that may influence attitudes toward death and end-of-life care. The findings also suggest the need for more research in this area to better understand and address the attitudes and needs of older adults as they approach the end of their lives.


INTRODUCTION
The world's population is getting older faster than ever. Most analysts believe this pattern will carry on for the next few decades, particularly in countries that have not experienced economic growth (Alekhina & Ganelli, 2020;Ben-Salha et al., 2021;Suhaimi, 2022). The total number of older people living in Malaysia increased to 2.17 million at the beginning of 2017, up from 2.07 million at the beginning of the previous year. The number of people in Malaysia under 14 decreased from 7.71 million in 2018 to 7.69 million in 2017, indicating that the country is following the lead of other developed countries in terms of an ageing society (Azeelah & Zafarina, 2022;Nungsari et al., 2022;Shafiee et al., 2022). This trend indicates that Malaysia is following the lead of other developed countries in terms of an ageing society. It is natural for older people to experience a decline in their overall resilience, including both their physical and mental health, as time passes (Feridooni et al., 2015;Hestad et al., 2021;Webber et al., 2020;Nik Husin & Aziz, 2021). This is a normal part of the ageing process. As a direct result, most people in their later years are at an increased risk of developing a disease that could ultimately prove fatal. Older people, in terms of age, are more likely to pass away, and they are more likely to suffer the unavoidable loss of a loved one. Even though death is inescapable for everyone, older adults need to prepare for when they pass away and have a plan in place.
There is a significant correlation between a person's outlook on death, their state of physical and mental health, and their overall sense of well-being. This connection holds regardless of whether or not the individual is religious. This is the case regardless of whether or not the person adheres to a religious tradition. Dering et al. (2022), According to research on psychopathology, a phobia of death is considered a reliable indicator of the severity of a person's mental illness. Older people are more likely to exhibit symptoms of depression after the passing of an older sibling (Dering et al., 2022;Mohammadi et al., 2022;Yuniati & Sitinjak, 2022). This is especially true for people who are in their later years. One's perspective on mortality has essential behavioural and emotional repercussions [8], particularly for adults of a later age.
Furthermore, attitudes toward death impact the quality of final arrangements and mortality rates (Lu et al., 2022;Sitinjak & Hurriyati, 2022). This is because attitudes play a role in determining how people cope with their impending death (Fischer & Secinti, 2022;Lu et al., 2022). Older adults cannot plan their follow-up care or discuss their preferences regarding death and dying if they avoid talking about it because they are afraid of it or avoid it. A pessimistic outlook on mortality can cause one to miss opportunities related to hospice care, quality palliative care, and death (Campbell et al., 2022;Zheng et al., 2022). Because of the significance of the relationship between attitudes toward death and health, attitudes toward death, and the quality of death, it is essential to have a good understanding of people's attitudes toward the passing of older people (Campbell et al., 2022;Zheng et al., 2022). Because of this connection, it is necessary to have a firm understanding of general attitudes that pertain to death.
The elderly are already a sizeable portion of Malaysia's population, and the country's population is ageing at a rate that is significantly faster than the average rate across the world. Several academic investigations have been carried out to investigate the views of older adults on the subject of passing away. You can locate some of these studies in this location. The subject of death is avoided as much as possible in traditional parts of Malaysian society because it is a taboo subject that should not be discussed. Because of this problem, the majority of Malay people choose avoidance strategies as a means of coping with the reality of death in order to lessen their awareness of it. This is because avoidance strategies are seen as less emotionally taxing. When speaking with older adults, death is considered awkward and disrespectful (Ganesan, 2022;Lew et al., 2022), and this death-sensitive culture stifles the growth of hospices and palliative care (Ganesan, 2022;Hod et al., 2022). Several studies have demonstrated that how individuals think about their mortality has a subtle but significant impact on older adults' lifestyles and quality of life. It is possible that they will not be able to live up to their full potential as individuals if they do not consider the fact that they are going to die. This is because they will not be able to face their mortality (Hod et al., 2022;Rafindadi et al., 2022).
Many studies concentrate on attitudes toward the deaths of medical professionals (Kolagari et al., 2022;Mulligan & Weil, 2022), medical students (Mulligan & Weil, 2022;Verma et al., 2022), and cancer patients, whereas attitudes toward the deaths of older adults receive little attention from researchers (C. Chen et al., 2022;Chowdhury et al., 2022;Tan & Venketasubramanian, 2022). In addition, the study's findings were inconsistent and varied, which could be attributed to differences in the experiences, religious beliefs, and cultural backgrounds of the object of the study. This would imply that an individual's perspective on death highly depends on his or her unique experiences (D. et al., 2005;Verma et al., 2022). People's positive and negative perspectives can be broken down into several distinct categories, which hold for positive and negative aspects of people's attitudes toward death. Therefore, it is essential to comprehensively understand older adults' perspectives on death and investigate the relevant factors that influence this perspective. This understanding should be based on research. Therefore, research ought to be the foundation for this comprehension. This will serve as a model for developing mortality education and psychological interventions for the elderly to reduce excessive anxiety and fear of death (Kolagari et al., 2022).
Death education is a set of educational activities designed to provide knowledge and skills about death and the events that occur in the years leading up to a person's passing (Siddiqui et al., 2021;Wynnychuk et al., 2021). Death education can also refer to the events that occur in the years leading up to a person's passing (Anagnostou & Cole, 2021;Ducray et al., 2021). A person may engage in these pursuits throughout their entire life. By teaching people, death is an unavoidable part of life, and death education strives to gradually teach people that death is an unavoidable part of life, thereby normalizing death and loss and improving death preparedness among the general population. Death education also aims to normalize death and loss. Research suggests that educating people about mortality can improve quality of life and well-being by lowering the prevalence of pessimistic attitudes toward death (Brightman et al., 2021;Martínez-Heredia, 2021b). This can be accomplished by reducing the number of people who view death as an adverse event. This can lead to a decrease in the number of individuals who are despondent about their impending death. The agony and helplessness of death are more likely to be experienced by older adults as the end of their lives draws near (Martínez-Heredia, 2021b, 2021a. Because of this, the provision of death education that is individualized to the characteristics and factors that influence older adults' attitudes toward death is more important than ever. This results from living longer in the United States, resulting in a higher average age at death. It helps older adults overcome the negative emotions associated with death and dying, contributes to active and healthy ageing, and increases the meaning of life (Mossenson et al., 2021;Thai et al., 2021). This study aims to contribute to the expansion of research on mortality attitudes all over the world. It is one of the few studies that has focused on the perspectives of older adults regarding the passing of a loved one, and it is one of the reasons why this study is essential.

METHOD
In Malaysia's Klang Valley, considered one of the country's urban areas, a crosssectional survey has been ongoing since November 2021. As a result, we distributed questionnaires to senior citizens living in communities at least sixty years old, have been residents of the community for more than a year and can communicate clearly with researchers. In addition, all the people who participated in the study were recruited through advertising; moreover, they did so voluntarily and verbally gave their consent. The following are the criteria for excluding participants from the study: (1) the participant must not have a permanent residence; (2) the participant must be younger than 60 years of age; (3) the participant must have impaired cognitive function (according to medical records) and must be unable to communicate effectively; (4) the participant must have other reasons for not participating in the study (such as an exacerbation of the disease, a terminal illness, etc.); and (5) the participant must not smoke.

Sociodemographic Form
This form was self-designed and included questions about gender, age, ethnicity, religion, marital status, education, average monthly income, type of job held before retirement, illness counts, conversations about life and death (conversations such as wills, funerals, resuscitation orders, preference for place of death, and after-care advice), as well as independence (self-assessment by an older adult to describe the basic skills needed to selfsufficiency such as eating, bathing, and shopping).

Death Attitude Profile Revised (DAP R)
The Malaysian Death Attitude Profile-Revised (DAP-R), which is a culturally adapted version based on the profile developed by Wong, Reker, andGesser in 1994 (Machado et al., 2019;Wong et al., 1994), was selected for the study of attitudes toward death, and its reliability and validity can be guaranteed (Reker, 1981;Sekowski, 2022). Reker (1981), in this study, Cronbach's alpha was 0.94, with 32 items. The five dimensions that make up the scale are fear of death (F.D., seven items), death avoidance (DA, five items), neutral acceptance of death (NAD, five items), acceptance of imminent death (AAD, ten items), and acceptance of death escaped death (AED, five items) (EAD, five items). Higher scores indicate that respondents have more intense feelings regarding each death attitude dimension, such as B. The scores range from one to five, with one representing "strongly disagreeing" and five representing "strongly agreeing." fear, neutral avoidance, or acceptance, etc. A score of 3.5 indicates a high level of recognition for the candidate.

Contents of the Form for Death Education
The author designed this form, containing ten sections covering various topics, including birth, death, referrals, hospitalization, and more. The current investigation discovered that Cronbach's alpha for this particular questionnaire was 0.96. The purpose of this study and the Death Education Content Complaint Form is to investigate and collect information that older adults want to know about life and death. Education about death for the elderly may be subject to additional regulations in the future. The participants raise the minimum quantities for each item to reflect their personal experiences, which are then reflected in the final tally. For each product, you have the option of selecting "desperately needed," "needed," "needed in general," "not needed," or "not needed at all." The participants in the study ranked all of the items higher than the other available choices, giving them ratings of "desirable," "needed," and "often needed" for each of the items in question.

Data Collection
The questionnaire was completed by hand in its entirety. In order to get a sufficient number of people to participate, workers at the hospital first put up posters with information in various areas and spread the word by word of mouth among the senior citizens in the surrounding area. These community members are tasked with making initial contact with prospective participants and facilitating interviews with the investigators. Following selecting participants according to the criteria for inclusion and exclusion, the first author provided a concise introduction to the survey's objectives, content, meaning, and caveats. Next, the participants were asked for their verbal consent and then given a written, structured questionnaire to fill out. As part of the survey, in-person interviews were carried out by seasoned research professionals. The individuals being interviewed sat quietly and waited patiently while the interviewer went through the questionnaire and took notes. After ensuring that every question was addressed during the interview, the interviewer had the participant sign the questionnaire before removing it from the room. There were 718 questionnaires distributed, and 683 valid responses were received (meaning they were mostly filled out). A total of 95,13 per cent of people answered the survey

Data Analysis
SPSS version 26.0 was used to perform the analysis of the gathered data. The findings from the measurements are depicted using means and standard deviations, whereas the findings from the calculations are displayed using frequencies and proportions. We used nonparametric tests for the univariate analysis between the groups, and we used multivariate linear regression analysis to determine the factors responsible for the observed differences. Even though the dependent variable did not have a normal distribution, the normality assumption of the residuals was validated in both the univariate and the multiple linear regression analyses. These analyses used various aspects of attitudes toward death as the dependent variable. (Appendix 1 contains more information on the results of the residual normality test.) There is still the possibility of carrying out multiple linear regression on the data (Bürkner & Vuorre, 2019). After that, a multiple linear regression analysis was carried out with the factors already determined to have statistical significance as the independent variables. The mode for editing variables has been changed to Systematic (Predicted probability of entering F = 0.05, Predicted probability of distance F >= 0.10). Because there is no collinearity among the variables, multiple linear regression analysis can be performed. In this study, statistical significance was determined to exist when the P value was less than 0.05.

FINDINGS
A total of 165 senior citizens, with a median age of 61, participated in the research, with 34% of the participants being male and 66% female. More than fifty per cent of people in their later years are married, with thirteen per cent having previous marriages. Participants in this study are primarily high school, middle school, and primary school students. Prior to their retirement, the vast majority of respondents had been employed in the industry sector. More than seventy-three per cent of the elderly participants in the study were suffering from chronic diseases, and ninety-one per cent had witnessed the passing of another person. On the other hand, fewer than half of older adults have engaged in conversations about life and death. For more details, see Table 1. Perspectives on death held by older adults residing in communities The results of the participants' scores on each dimension of their attitudes toward death are presented in Table 2. The total score closest to death acceptance had the highest average out of all aspects of mortality attitude, coming in at 43.88 9.23, while the score closest to death receipts had the lowest average, coming in at 12.30 4.27. In addition, the dimension of neutral death acceptance received the highest number of item scores (5.53 0.73), followed by death avoidance (4.85 0.61), and fear of death received the lowest number of item scores (2.34 0.69). The findings of the univariate analysis suggest that the fear of death is influenced by factors such as marital status, religious affiliation, educational attainment, the capacity for selfcare, the number of diseases, and conversations about life and death. Various factors, including self-care ability, exposure to several diseases, and previous involvement with other people's passing, impact death Avoidance. Age, religion, and conversations about life and death influence neutral Acceptance of Death. A person's ability to self-care, number of illnesses, level of education, and income all play a role in whether or not they are allowed to die. Escaping Acceptance of Death is influenced by factors such as income and discussion about life and death for more details in Table 3.

DISCUSSION
Many older people, especially in Malaysia, are experiencing health issues because of the country's rapidly ageing population. Since the elderly are more likely to die as a result of their increased susceptibility to illness and their increased experience of sadness as a result of social isolation, it is essential to understand how they feel about dying; the present investigation is thus mainly concerned with identifying the factors that shape the perspective of the elderly. Social value for the elderly is expected to increase because of the study's findings, which will facilitate the achievement of healthy and active ageing. Due to cultural constraints, deathrelated studies are still uncommon in Malay. This study is one of the few that has focused on people's perspectives on death in a population primarily comprised of their senior peers. This discovery can help them better prepare for death and the challenges of old age.
The attitudes of community-dwelling older adults toward death Previous studies on death anxiety among adults in the U.K. have shown that anxiety levels decrease with age. This is in line with research on adults in Korea, which found that older people perceive death more positively, so it does not cause anxiety. In this study, acceptance of death among parents has a positive value (N. et al., 2017). This study's results also show that older respondents positively view neutral deaths. Even though the level of education in this survey varies, the results of this study show that they can see death as the final stage of their life in this world. This is likely influenced by their experience of the death of others around them.
This study also revealed that, despite their advanced age, a significant proportion of respondents wished to avoid death. This shows that even though research participants can accept their death as a part that must happen during their lives, most still avoid discussing deathrelated issues, such as what they should do before they die (Ong et al., 2021). By avoiding death-related conversations, individuals indirectly reduce their awareness of death, their acceptance of death, and the quality of death itself. In addition, this attitude can lead to depression or other mental illnesses that are detrimental to their mental health (P. Chen et al., 2020;Mengelers et al., 2019).
The research findings also indicate that when older adults are confronted with their mortality, they can accept it from a realistic standpoint, eliminate their desire for material possessions, and abandon their fear of death. This study also rated low fear of death in contrast to previous studies where death anxiety among elderly Iranians was relatively elevated. The average respondent in this study has a chronic illness and lives in an elderly community, which causes difficulties with self-care. Furthermore, they avoid discussing death frequently, so their fear and anxiety are relatively low.
Factors influencing attitudes toward death among older adults living in the community Numerous studies have identified several factors that can influence attitudes toward death; these factors are closely related to cultural backgrounds dissimilar to the research's subject. For example, in Malay culture, their environment, diseases, marital status, income, and diseases heavily influence older adults' attitudes in learning communities.
Many diseases afflict the elderly and can heighten their dread of death when afflicted individuals are healthy; their scores for fear of death, avoidance, and acceptance of death decrease (Montoro-Rodriguez et al., 2021). This demonstrates that the number of diseases a person has will affect his or her thought process and the attitude of the elderly towards death. As the number of diseases rises, the adverse effects of death, avoiding death, and escaping death will diminish. This indicates that the presence or absence of disease in the elderly significantly impacts a person's outlook on death. Diseases are endured because they heighten individuals' awareness of their mortality. When older adults are diagnosed with a life-threatening illness, these results indicate that healthcare professionals must pay attention to changes in their mindset and psychology (Mengelers et al., 2019;Montoro-Rodriguez et al., 2021).
Discussing life and death can affect a person's fear when confronting death (Horne et al., 2012). Conversations about life and death positively affect older adults' acceptance of death and reduction of death avoidance. Relevant conversations about life and death can heighten adults' awareness of death and their conviction that it is unavoidable. Overall, discussions of life and death have impacted all dimensions of community-dwelling on older adults' attitudes toward death except death avoidance. Life and death discussions are a double-edged sword that must be handled with care (Horne et al., 2012;Ivanova, 2015).
On the one hand, it can increase older adults' awareness of death and encourage them to accept death neutrally. However, on the other hand, there may also be fear of death, approaching and avoiding acceptance of death (Kohara & Inoue, 2010;Razaz et al., 2017). Therefore, additional research is required to determine how to standardize or appropriately conduct lifeand-death conversations with older adults.
Cancer patients are also influenced by their marital status regarding their fear of approaching death. Individuals desire to continue living with their partners significantly affects their rejection of death, which is influenced by marriage (Sineokaya, 2019;Ujung & Kodim, 2020). This may be due to their life experiences, which give them a sense of happiness when they are with their partners and a high fear of death. Because remarriage demonstrates the ability of parents to integrate into a new life and find happiness again, it causes the elderly to fear death because they will be separated from their partners (Horne et al., 2012;Ivanova, 2015;Kohara & Inoue, 2010).
The study's results also found that age is a factor that significantly influences an individual's attitude toward death. In this study, attitudes toward death among the young population (60-69 years), middle-aged (70-79 years), and elderly (over 80 years) differ only in the dimensions of death. The older a person is, the lower their social impact can affect them. The findings also prove that other people's experiences in dealing with death make individuals aware that soon they will accept the same thing, namely death, and begin to realize that death is a law of nature.
Attitudes toward death in elderly adults in Malaysia are shaped by a variety of social factors. One such factor is religion, which is deeply ingrained in Malaysian culture and plays an important role in shaping beliefs and practices related to death. Islam, for example, the predominant religion in Malaysia, places great emphasis on the afterlife and the importance of preparing for it. As a result, many elderly Malaysians view death as a natural and inevitable part of life, and believe that preparing for it is a necessary part of their religious obligations. Other social factors that can impact attitudes toward death in elderly adults in Malaysia include family and community attitudes, cultural beliefs, and socioeconomic status.
In addition to religion and other social factors, attitudes toward death in elderly adults in Malaysia may also be influenced by individual factors such as personality, life experiences, and health status. For example, research has shown that individuals who have experienced the death of a loved one may have a more accepting attitude toward death, while those who are experiencing health problems may be more fearful of death. Despite the many factors that can impact attitudes toward death in elderly adults in Malaysia, it is clear that social factors play a significant role in shaping these attitudes. Understanding the impact of these social factors is important not only for helping elderly adults in Malaysia prepare for the end of life, but also for improving end-of-life care and support in the country.

CONCLUSION
This study is one of many related studies examining people's attitudes toward death in Malaysia. The country of Malaysia was the focus of this particular study. The perspectives on death that are not exhibited by the elderly are complex and multidimensional. Several factors, including illness, conversations about life and death, marital status, and income, can influence an individual's perspective on death. People in their later years who live in the community have a keen interest in activities that can bring them a level of joy they may not have experienced previously. This study can also be used as a reference for additional research to address the problem of elderly unpreparedness and improve the quality of death that will be faced by the elderly.
The study contributes to our understanding of attitudes toward death among older adults in Malaysia's Klang Valley. However, there are several limitations that should be addressed in future research. The study only investigated a limited number of social factors that may influence death attitudes, and did not explore other potential factors that may also play a role. Additionally, the study used a cross-sectional survey design, which may limit the ability to draw causal conclusions about the social factors that influence death attitudes in the elderly. The findings are also limited in their generalizability, as the study only focused on older adults in Malaysia's Klang Valley.
To address these limitations, future studies could investigate a broader range of social factors that may influence death attitudes, such as cultural norms and values, religious beliefs, and past experiences with death and dying. Qualitative studies could provide more in-depth insights into the personal experiences and perspectives of older adults regarding death and endof-life care, which could provide more detailed information about the complex factors that influence death attitudes in this population. Longitudinal studies could also be conducted to better understand the changes in death attitudes over time and the causal relationships between social factors and death attitudes in the elderly. Finally, the findings suggest the need for healthcare providers and policy makers to consider social factors that may influence death attitudes and end-of-life care among older adults, which should be a focus of future research.