To our knowledge, this is one of the first national studies to investigate the discrepancies among the awareness and attitudes toward ACP between medical and non-medical university students in mainland China. The study provides additional information about influence factors related to the awareness and attitudes of ACP among university students. These findings are useful for the development of suitable interventions to improve the awareness and attitudes toward ACP of university students and to help them make appropriate decisions for elders and their own eventual ACP process, even if it does not occur in the future.
In the study, 59.89% of the students had never heard of ACP, which is lower than a previous survey of awareness of ACP among adolescents at 14 to 21 years of age (72%) in America , but it is similar to a recent study of undergraduate nursing students (65.9%) in China . The low level of awareness of ACP among university students in mainland China was mainly related to the lack of advanced medical education. The results also showed that medical students have higher levels of awareness than non-medical students, which was congruent with the findings in a study that emphasized the impact of training courses concerning ACP on university students . Regarding the difference in awareness toward ACP between medical and non-medical students, the government should focus on health education, such as life-death education on university students.
Despite under-education on ACP, the majority of participants showed positive attitudes toward it, and the results of this study had documented their strong willingness to engage in ACP discussion in the future (82.45%). This result is inconsistent with that among American university students, which reported lower willingness levels (73%) in creating an advance directive. The high willingness rate in our study may be related to the reported grade, religion, and education. Firstly, we excluded senior students as they were in their internships. However, it has been reported that university students in the first 3 grades had a stronger willingness to participate in ACP than their seniors. This may be due to that they were younger, more premature, and did not know the difficulties in the implementation of ACP in real life. Secondly, 95.4% of the participants in the study had reported no religion. It has also been shown that university students who had no religion were more likely to carry out ACP than those who had a religion . Thirdly, all participants recruited in this study were university students who had high education levels. In the previous studies, higher education was associated with greater awareness and preference for ACP [2, 3, 20]. Therefore, from our perspective, as a well-educated population without any religions, university students had open-minded thinking and a higher proportion of considering ACP. They may be less influenced by Chinese traditional culture and death taboo compared to those who have lower education levels. It may be that all these factors lead to the statistical balance of the level of willingness between medical and non-medical students. This unexpected result was found to be similar to a recent study of the attitudes toward ACP among Chinese clinical nurses which showed that the nurses who did not receive any school education of palliative care were more likely to participate in ACP than those who had relevant knowledge . This study also found that medical students had more experience in making their own treatment decisions (P = 0.005) than non-medical students. A possible explanation is a professional knowledge including medicine, nursing, clinical practice, and medical ethics influenced medical students’ autonomy and self-determination.
In the study, the more medical education the university students had, the awareness of ACP and the involvement in important treatment decisions were better. It has been discovered that medical education was the factor that influenced the awareness of the proxy decision-maker (P = 0.028) and the end-of-life decision making (P = 0.000) among university students, which was consistent with findings in the other study . In China, medical education has an unignorable promoting influence on the awareness of ACP. When medical students were equipped with medical knowledge, they would better be prepared to understand and facilitate ACP discussions.
To date, many studies regarding ACP have focused on older adults. As a major force for positive social and economic change, university students are needed to be studied. Since university students are in the process of psychological development and identity transitions, their knowledge of ACP and competence relating to ethical end-of-life decision-making are proved to be deficient. This will result in their families and themselves receiving unsatisfactory care near the end of their lives . Therefore, more ACP educational interventions need to be put on young people especially these well-educated university students to help them make a better judgment at the end of life or act as surrogate decision-makers for their elders if needed.
Strengths and limitations
This study contributes to the sparse information about the awareness and attitudes toward ACP among university students in mainland China. Due to all questionnaires were spread by their teachers through the WeChat group, the response rate (79.81%) and the effective questionnaire rate (93.13%) of the initial samples was relatively high. These high rates contributed to the reduction of the selection bias caused by the loss of samples and uncompleted answers.
However, several limitations in this research need to be acknowledged. Firstly, although participants came from 12 universities in 4 provinces, they were all living in the east part of China with higher GDP, so this student group cannot represent Chinese university students. Secondly, as the reliability of the Chinese version of the questionnaire can be accepted among university students, so we did not conduct a pilot study to test and improve it. Thirdly, as young adults have their particularities, most of them were single, healthy, living with their parents or roommates without too much social experience, many potential factors such as age, occupation, monthly income, and so on were not compared and discussed deeply. This may limit the generalizability of the findings of young populations.
Further studies of this population are needed to better understand the differences between medical and non-medical university students as well as appropriate interventions to redress the disparity and to improve the awareness and attitudes regarding ACP among university students.
Discrepancies mainly existed in the awareness of ACP among medical and non-medical university students, and it was similar to the results in a previous study . In order to redress this disparity, firstly, educational initiatives such as establish general life-death courses and develop ACP training programs may help university students better understand end-of-life decision-making, facilitate ACP conversations, clarify their options, explore the values and preferences of themselves and others, and advocate ACP . Secondly, it is imperative to build models for peer-led ACP initiatives. The social identity theory suggested that students may have been more receptive to the workshops because they were members of their in-group. Therefore, the workshops on ACP with behind-the-scenes support from older professionals need to be developed and presented for university students to participate in ACP . Thirdly, the policies, laws, and regulations on ACP should be established and perfected by the governmental departments to regulate the implementation of ACP in mainland China.